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THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




CLASS- 



K'^.rc^ tjftok' 



BOOK_ 



PRESENTED BY 



) ■. 



:> 



O F 



(J/OL i/O^^-^ 



S Y S T "E M 



S U 



G E R Y 



BY 

BENJAMIN BELL, 

MEMBER OF THE ROYAL COLLEGES OF SURGEONS 

OF IRELAND AND EDINBURGH, 

ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, 

AND FELLOW OF THE ROYAL SOCIETY 

OF EDINBURGH. 



ILLUSTRATED WITH COPPERPLATES. 



VOLUME V. 
lEE THIRD EDITION CORRECTED. 



-% 




EDINBURGH: 

Printed for CHARLES ELLIOT, Edinburgh ; 

C, E L L I O T Sf T. K A Y, No. 334, Stiar.d ; and 

G. G.j' & J. ROBINSON, London, 

M,DCC,LXXX!X. *» 



CONTENTS. 



CHAP. XXXVJ. 

Page 
Of Wounds, q 

SECTION I. 

Of Wounds in general, - ' « 9 

SECTION II. 

Of the Cure of Simple Incifed Wounds, 34 

SECTION III. 

Of Pun6lured Wounds, %oi 

SECTION IV. 

. Of Lacerated and Contufed Wounds^ 116 

SECTION V. 

Of Wounds in the Veins, - - l^"^ 

SECTION VI. 
Of Wounds in the Lymphatics, ^ l^§ 

SECTION VII. 
Of Wounds in the Nerves and Tendons, and 
of Ruptures of the Tendons, 138 

A 2 3 E C- 



iv CONTENTS.. 

Page 

SECTION VIII. 

Of Wounds in the Ligaments of Joints^ ^c. 1 5 1 

SECTION IX. 
Of Wounds in the Face, - 166 

SECTION X. 
Of Wounds in the Trachea and Oefophagiis, 170 

SECTION XL 
Of Wounds in the Thorax, - 180 

§ I . General Re?narks on Wounds in the 

Thorax, i8o 

§ 2. Of Wounds in the External Tegu- 

'??ients of the Thorax, 196 

§ 3. Of Wounds which penetrate the Ca- 
vity of the Thorax, 201 
§4. Of Wounds of the Lungs, 210 
§5*0/^ ^^'ounds of the Heart and Large 
Veffels co7ineded with it, and of 
Wounds of the Thoracic Dud, 222 
§ 6. Of Wounds of the Diaphragm, Me- 

diafiinian, and Pericardium, 226 

SECTION XII. 

Of Wounds in the Abdomen, 232 

§ I . Anatomical Defcription of the Ab- 
domen and parts contained in it, 232 
§ 2. Of Wounds of the Teguments and 

Mufcles of the Abdomen, 242 

§ 3- Of 



CONTENTS. V 

Pa';e 
§ 3* Of Wounds %vJjich penetrate the Ca- 
'vity of the Abdomen, hut which 
do not injure any of the contained 
parts, 250 

§ 4. Of Wounds of the Alimentary Qanal, 274 
§5. Of Wounds of the Stomach, 289 

§ 6. 0/" Wounds of the Ofnentum and 

_ Mefentery, 292 

$7' Of Wounds of the Liver and Gall- 
Bladder, 294 
§8. Of Wounds of the Spleen, Pancreas, 

and Receptaculum Chyliy 298 

$ g. Of Wounds of the Kidneys and U- 

reters, 300 

§10. Of Wounds of the Bladder, 303 

% \i. Of Wounds of the Uterus and its 

Appendages , 307 

SECTION Xlll. 
Of Poifoned Wounds, 3 1 2 

SECTION XIV. 

OfGunJhot Wounds, 325 

CHAP. XXXVII. 
Of Burns, , _ ^rn 

CHAP, 



vi. CONTENTS. 

CHAP. XXXVIII. 



Page 



Cy Tumors, 3^2 
SECTION I. 

OJ Tumors in General, 3"" 

S E C T I O N II. 

Of Acute or hijiammator'j Tumors ^ 3 " 5 

§ I. Of Eryjipelas, 37^ 

§2. Of Injlamination of the Ear, 382 

5 3. Of Angina, 3^4 
§ 4. 0/ Inflammation and Abfcefs of the 

Liver, 3^7 

§ 5. 0/ Inflammation and Ahfceffes in 

the Breafls of Women, 39^" 

% 6. Of Inflammation of the Tefles, 4°Z 

S J. Of Venereal Buboes, 4-^5 

§ 8. Of Lumbar Abfceffes, 4*9 

§ 9. Of the Paronychia or Whitlow, 43 ^ 

§ 10. Of Chilblains, 440 

§ 1 1. Of Sprains and Contufions, 44^ 
SECTION III. 

Of Chronic or Indolent Tumors, 45^ 

§ I. Of Encyfled Tumors, 457 

§ 2. Of Ganglions, 47^ 
§3. Of Swellings of the Burfa Muco/a, 479 
§ 4. 0/ Colleciions within the Capfular 

Ligaments of Joints, 4^5 

ss- Of 



CONTENTS. vii. 

Page 

S 5- Of Concretions and preternatural 
Excrefcences within the Capfular 

Ligaments of Joints , 491 

§ 6. Of Anajarca or Oedema^ 499 

% y. Of the Spina Bifida^ 502 

% S. Of Scrophulous Tumors, 507 

§ 9. Of the Bronchocele, 514 

§ 10. Of Navi Materni, 528 

S I \. Of Warts, 533 

§12.0/" Flefhy Excrefcences, 537 

§ 13. Of Corns, 539 
§ ^4. Of a fimple Exo/iofis, Venereal 

Nodes, and Spina Ventofa, 540 



A SYSTEM 



A 

TREATISE 

ON THE 

THEORY AND PRACTICE 
o F 

S U R G E R Y. 

CHAPTER XXXVL 
Of Wounds. 



S E C T I O N I. 

Of Wounds in general. 

VARIOUS definitions have been gi- 
ven of the term Wound ; but few 
if any of them appear to be exadl. Boer- 
haave defines a wound to be, a recent 
bloody folution of continuity in any foft 
part, by the motion, preiTure, or refift- 
VoL. V. B ance 



lo Of Wounds in general. Ch. XXXVI . 

ance of fome hard or Iharp body. By 
Sauvages, it is faid to be a mechanical di- 
vifion of any flefliy part, attended with a 
feparation of the parts newly divided, to- 
gether with a difcharge of blood and a 
tendency to inflame and fuppurate. And 
Ludwig defines a wound to be a morbid 
divifion of parts which in a ftate of health 
ought to be united. 

Thefe are the definitions of this term 
which have been moft generally adopt- 
ed ; but it is evident that none of them 
are fufiiciently correal. A part may be 
deeply cut, even large blood-veflels may 
be divided, without any difcharge of blood 
taking place, as frequently happens in la- 
cerated wounds, and in fuch as are attend-- 
ed with much contufion : and where the 
fmaller vefi[els only are divided, the dif^ 
charge of blood ceafes, almoft in every in- 
flance, in the courfe of a few hours from 
the time that the wound was inflidled. 

The definition recited above from Mr 
Sauvages is too extenfive : It compre- 
Bends a period or ftage of wound which 

do^s 



Sed. I. Of Wounds in general. 1 1 

does not always exift, viz. a tendency 
to fuppurate. We know that wounds 
frequently terminate in gangrene and 
death, without any previous fuppuration ; 
while in other inftances they heal by the 
firfl: intention, and their edges adhere to 
one another without any appearance of 
pus. 

Neither is Dr Ludwig's definition of a 
wound correiSl : Parts which ought to be 
united, may be divided without being 
wounded. Thus a blood-veflel, nerve, 
tendon, or mufcle, may be completely 
ruptured either by a violent fprain or a 
contufion; but unlefs the correfponding 
fldn and other teguments are divided, 
we do not fay that fuch parts are wound- 
ed. Nor are thefe afFedions confined to 
the fmaller mufcles and tendons ; for in- 
ftances often occur of the different parts 
even of the largeft mufcles being thus vio- 
lently feparated from one another. 

Every recent folution of continuity in 

the fofter parts of the body, when attend- 

B 2 ed 



12 Of Wounds in general. Ch. XXXVL 

dd with a correfponding divlfioii of the 
teguments, may be denominated a wound. 

From this definition of wounds, it is 
evident that tliey will exhibit great va- 
riety in their nature and appearances. 
Tliis will arife from different caufes, but 
more particularly from the nature of the 
injured parts ; from the manner in which 
they have been produced ; and from their 
extent. 

Thus wounds in flefliy mufcular parts 
are very diiferent, both in their nature 
and appearances, from fuch as affeft mem- 
branous or tendinous parts only. Wounds 
that are made with a (harp cutting In- 
flrument are materially different from 
fuch as are attended with much contufion 
or laceration : and punctured wounds 
exhibit very different appearances, and 
for the mofl part are productive of very 
different effe(fts, from fuch as are more 
free and extenfive. In the fubiequent 
parts of this fe<ftion thefe varieties in 
wounds will be confidered. In the mean 
time, we fliall give a defcription of the 

phenomena 



Se£l. I. Of Wounds in general. 13 

phenomena which nfually take place in 
the moft frequent form of this afFecftion, 
what may be termed a Simple Incifed 
Wound ; by which both the theory and 
pradice which we mean to inculcate will 
be rendered more intelligible. 

On the inftrument being withdrawn 
with which a wound of this kind has been 
made, the firft appearance we take notice 
of is a reparation to a certain extent of 
the divided parts ; and this always in a 
greater or leffer degree, according to the 
depth and length of the wound, and ac- 
cording as the fibres of the injured part 
are divided more or lefs tranfverfely. 
Thus a wound, even of a confiderable 
length, if it runs in the fame diredlion 
with the fibres of a mufcle, will be at- 
tended with a fmall retradion of the fkin; 
while a large vacuity will take place in a 
wound of lefs extent where a flrong muf- 
cular part is cut diredtly acrofs. Nay, 
in this lafl cafe, the reparation of the divi- 
ded parts is in fome cafes fo confiderable, 
as to give caufe to fufpedl that a portion 
B 3 of 



14 Of Wounds in general. Ch. XXXVI. 

of them has been removed ; while in the 
other it is often fo trifling, that even an 
extenfive wound will have the appearance 
of a {Iraight line only : a circumftance by 
which pra<flitioners have been often led to 
confider as of no great importance, wounds 
which in their confequences have proved 
to be formidable ; and by which the pro- 
priety of examining every wound with at- 
tention is flrongly pointed out. 

The next appearance which takes place 
in wounds, is a difcharge of blood to a 
greater or lelTer extent, according to the 
fize of the cut, and to the number and 
fize of the vefTels that are divided ; at 
leaft this is the cafe in wounds made with 
a fliarp cutting edge. Where the parts 
have been much bruifed or lacerated, we 
have already remarked, that even large 
blood- vefTels may be divided without any 
hemorrhagy enfuing. 

For the moft part, this evacuation of 
blood from wounds proves fo alarming 
that means are employed to flop it ; but 
when this is either negledled or not con- 

fidered 



/ 



Scft. I. Of Wounds in general. 15 

fidered as necelTat-y, if the injured vefTels 
are not large, the irritation produced by 
the wound itfelf, as well as by the free 
application of the external air to their 
divided extremities, excites fuch a degree 
of contradion in them, that in this way 
alone the hemorrhagy is foon checked. 
The difcharge of red blood becomes gra- 
dually lefs : It then ceafes entirely, and 
is fucceeded by an oozing of a ferous 
fluid, which in the courfe of a few hours 
likewife flops, when the whole furface of 
the fore is found either fomewhat dry or 
even parched-like ; or it is covered over 
with a cake of coagulated blood. 

In this way nature feems to operate 
in putting a flop to hemorrhagies which 
arife from wounds. Another idea is com- 
monly entertained indeed of this falutary 
. procefs ; It is fuppofed that fmall coagula 
of blood plug up the orifices of the vef- 
fels, and remaining in them preferve them 
of the fame fize of which they were be- 
fore being divided. 

This, however, is by no means the cafe, 
B 4 as 



1 6 Of Wounds in general. Ch. XXXVL 

as will at once appear to any who will 
take the trouble of differing the flump 
of a patient dying after an amputation, 
Inftead of the mouthf> of the divided ar- 
teries being plugged up with blood, he 
will find them perfedly empty and con- 
tracled for a confiderable fpace from 
their extremities ; nay, in moll inftances, 
he will obferve that they become firm 
folid cords, fo as never afterwards to be 
capable of receiving a fupply of blood. 
Nor is this procefs of nature difficult to 
explain. It is arterial hemorrhagies we 
are now confidering; for wounded veins, 
\i they be not comprefTed between the 
injured part and the heart, feldom dif- 
charge fo much blood as to prove alarm- 
ing. Now, as the arteries are pofTeffed 
of a ftrong contradile power, they will 
readily exert this power on the irritating 
caufes mentioned above as attendants on 
wounds, being applied to them. In this 
manner the blood is prevented from flow- 
ing in its ufua] channel ; but nature does 
pot fail to provide a different route for it, 

b.y 



Se6l. I. Of Wounds in general. 17 

by forcing it through the mod contigu- 
ous anaftomofing arteries, which foon 
become fo much enlarged, as to allow it 
to pafs with freedom ; while, in the mean 
time, the contraded ftate of the wound* 
ed extremities of the arteries terminates 
in a firm adheiion of their fides, in con- 
fequence of that inflammation which in 
fome degree fucceeds to every wound. 

When a wound is made with a clean 
cutting inftrument, the pain attending it 
at firft is in geperal inconfiderable, un- 
lefs a nerve or a tendon has been partial- 
ly divided j in which cafe it proves com- 
monly fevere. But in every cafe the 
wounded parts become painful in the 
courfe of a few hours from the time of 
the injury being infli6led. They become 
red, tenfe, and even confiderably fwelled : 
And where the wound is extenfive, an 
increafed degree of heat takes place, to- 
gether with thirft, quicknefs of pulfe, and 
pther fymptoms of fever. 

|n fome inftances thefe fymptoms con- 
tinue 



1 8 Of Wounds in general. Ch. XXXVI. 

tinue to increafe, and to prove more and 
more fevere, till at laft they terminate in 
mortification ; but for the moft part they 
are carried off in a more favourable man- 
ner. The furface of the wound, which for 
fome time remained pcrfedlly dry, is gra- 
dually rendered moift and foft by a thin 
ferum oozing into it ; which being allow- 
ed to colle(51:, is at laft, by the heat of the 
afFeded parts, and in fome cafes by the 
application of artificial heat, converted 
into purulent matter : and in general, the 
preceding fymptoms of pain, tenfion, and 
fever, abate more or lefs quickly accor- 
ding as this formation of mattef is more 
or lefs plentiful. From the time that fe- 
rum begins firft to ooze into the cavity 
of a wound, the tenfion and pain begin 
to abate, and they vanifh entirely on a 
free fuppuration taking place ; by which 
the moft natural balfam is produced that 
can be applied to wounds. 

From this hiftory of the progrefs of a 
wound, it is evident that all the fymptoms 

we 



Sc£t. I. Of Wounds in general. 19 

we have enumerated, are fuch as origi- 
nate from inflammation. Indeed, they 
are exadlly fuch as accompany a common 
phlegmon. The pain, rednefs, and ten- 
fion, which always accompany wounds 
to a certain degree, are the leading fymp- 
toms in every cafe of phlegmon; and 
the ferous eflfufion into the cavities of 
wounds, with the fuppuration which en- 
fues, are circumftances exadlly fimilar to 
thofe which occur in every cafe of ab- 
fcefs. I therefore confider a wound as 
an exciting caufe of inflammation ; and 
fome advantage, I think, may be derived, 
in pra^ice, from confidering it chiefly in 
this point of view. This, however, will 
more clearly appear when we come to 
fpeak of the method of cure; when it will 
be rendered obvious, that in the treat- 
ment of wounds, thofe means prove uni- 
formly mod effedual which are moft 
powerful in preventing any violent de- 
gree of inflammation- 
The defcription I have given of wounds 

relates 



so Of Wounds in general. Ch. XXXVI, 

relates to the mod fimple and lead ha- 
zardous kinds of them ; where the inju- 
ry has been done, as was already remark- 
ed, with a (harp cutting inftrument, and 
where the parts have been laid free- 
ly open. In fuch circumftances, when 
no organ of much importance to life has 
been divided, and when the cut is feated 
in a flefhy mufcular part, if nature be not 
impeded in her operation, the whole fur- 
face of the fore becomes covered with 
fmall fprouts or granulations almoft im- 
mediately on a free fuppuration taking 
place ; and thefe continuing to advance, 
a cure is at laft accompliChed in the man- 
ner already defcribed in a former part of 
this work *. 

This happy termination of a wound, 
however, may be prevented by various 
caufes. Indeed, it requires the concur- 
rence of many circumftances. Thefe we 
flaali afterwards have occafion to treat of 

in 

* Vide Treatife on the Theory and Management of Ulcersj 
&c. Part II. Sedion II. J 2. 



Se£t. I. Of Wounds in general. it 

in a particular manner. At prefent I 
fliall enumerate tliofe only wliicli arife 
from the nature of the wound. 

In a free inclfeci wound, the inflam- 
mation which takes place is not in gene- 
ral greater than is necelTary to produce 
that degree of fuppuratlon which we have 
lliown to be requifite ; and in wounds of 
this defcription, matter is never allowed 
to lodge, as it is commonly difcharged al- 
mofl: as foon as it is formed, Thefe are 
points of the utmofl: moment in the ma- 
nagement of wounds. Indeed, it is known 
to every practitioner, that a cure can ne- 
ver be expe(^ted if adue degree of inflam- 
mation does not take place, and if a free 
outlet be not given to the matter that 
may form. Every circumflance there- 
fore in the nature of a wound, which 
tends either to excite an undue degree 
of inflammation, or to produce a lodge- 
ment of matter, muft be confidered as 
unfavourable : And hence pundlured 
wounds, and thofe that are attended with 

contufion 



22 Of Wounds in general. Ch. XXXVI. 

contufion or laceration, are particularly 
hazardous. 

Pun6lured wounds prove often more 
dangerous than wounds of greater out- 
ward extent, from large blood-veflels and 
other deep-feated parts being hurt; and 
they are commonly more painful, being 
frequently attended with a partial divi- 
fion of contiguous nerves or tendons ; a 
circumftance productive of more violent 
pain than what ufually enfues from a free 
divifion of them. But the greateft rifk 
in a puncflured wound arifes from the 
lodgement of matter ; a circumftance 
which takes place more readily in this 
than in any other variety of wound ; and 
to obviate which, the niceft attention on 
the part of pradlitioners is often requi- 
fite. 

In contufed and lacerated wounds, if 
the violence with which they have been 
inflidled has not been confiderable, the 
parts will frequently recover their tone ; 
the attending inflammation will not run 
to any great length ; and a free fuppura- 

tion 



Se£l. I. Of Wounds in general* 23 

tion being induced, a cure will at la ft be 
accompliflied in a manner fimilar to what 
we have defcribed in cafes of fimple in- 
cifed wounds. But it often happens that 
the contiguous parts are fo much injured 
as to give no caufe to expedl fuch a fa- 
vourable event. Where a violent degree 
of contufion has been applied, the tex- 
ture of the parts affedled is fometimes fo 
completely deftroyed, that the circulation 
is flopped, and mortification enfues ; and 
where this proceeds to any confiderable 
extent, the danger attending it is al- 
ways great. Again, in wounds attended 
with much laceration, mortification is 
apt to occur from a different caufe. 
The pain and irritation attending them 
proceed fometimes to fuch a height, as 
to induce a great degree of inflamma- 
tion ; which, notwithftanding the means 
ufually employed to prevent it, very 
frequently terminates in the manner 
we have mentioned. Indeed, fo far as 
my obfervation goes, inflammation indu- 
ced by this caufe is more apt to ter- 
minate 



(Z4 Of Wounds in general. Ch. XXXVL 

ttiinate in gangrene tlian any other in^ 
flammatory affe(rtion proceeding from 
external violence. 

In forming a prognofis of wounds, the 

circumllanccs we have juft been confi- 
(lering merit our particular attention: 
but there are others which fliould like- 
wife be kept in view ; and thefe n>ore e- 
fpecially are, the age and habit of body 
of the patient; the texture of the wound- 
ed part ; the part of the body in which 
the injury is inflidled ; and the n{k of 
fuch parts of importance as lie contigu- 
ous being ultimately made to fuffer, al- 
though not immediately injured. 

Thus, it is obvious, that in a found 
healthy conititution, wounds will, caete- 
ris paribus, be lefs hazardous than thofe 
that are inflidied on people of difeafcd 
habits of body; for we commonly ob-^ 
ferve, where the conftitution is tainted 
with any difeafe, that even the flightefl 
wounds are apt to become troublefomc, 
and to degenerate into fores which will 

not 



Stft. I. Of Wounds in generah 25 

not heal till the difeafe of the fyftem 
be removed : And we alfo obferve, that 
the healing of fores depends in feme 
meafure upon the age of the patient ; that 
is, a cure is for the moft part more quick- 
ly accomplifhed in youth and in middle 
age, than in very advanced periods of 
life. 

There are many exceptions, however, 
to this ; for whenever the natural firm- 
nefs and elafticity of the mufcular fibres 
are not much impaired, we do not find 
that old age proves unfavourable to 
wounds. "When the conftitution is pof- 
feffed of fuch a degree of firmnefs and 
irritability, that any wound which takes 
place will be producflive of a nccefTary 
degree of inflammation, old age ought by. 
no means to be confidered as a difadvan- 
tage. On the contrary, in fuch circum- 
flances it proves always falutary, by tend- 
ing to render the fymptoms more mode- 
rate than they are apt to be in more early 
periods of life. This is particularly the 
cafe in extenfive wounds of every kind : 

Vol. V. C and 



26 Of Wounds in getieral. Ch. XXXVL 

and we obferve it in a remarkable man- 
ner in chirurgical operations ; efpecialiy 
in lithotomy, and in the amputation of, 
any of the extremities ; which have com- 
monly, in the courfe of my experience, 
proved more fuccefsful in healthy old 
people than at any other period of life, 
and evidently from the caufe we have en- 
deavoured to point ovit. 

With refpei^ to the texture of a wound- 
ed part, it is well known that wounds 
heal not only more quickly but more 
kindly in fome parts than in others. 
Thus wounds of the cellular fubftance heal 
more ealily than fuch as pafs through 
any of the mufcles ; while thofe that are 
confined to the fieihy parts of mufcles 
prove much lels formidable than wounds 
of tendinous or ligamentous parts ; for, 
befides occafioning lefs pain and inflam- 
mation, they are not fo apt to be produc- 
tive of any permanent difadvantage. The 
deepeft cuts may be infliAed on the belly 
of a large mufcle, with little or no rifk 
of any ineonveniency being experienced 

from 



Sedt. I. Of Wounds In general, 27 

from them in future ; but the contigu-^ 
ous joints arc very apt to remain ftifF 
and unmanageable, when the tendons 
which pafs over them are much injured. 

When wounds penetrate to a (till 
greater depdi, fo as to do any material 
injury to bones, they prove always more 
tedious and uncertain than when foft 
parts only are divided ; for in fuch cafes 
a wound will feldom or never heal till 
fome portion of the bone exfoliates ; a 
procefs which very commonly requires a 
confiderable length of time to be accom- 
pliQied *. 

Wounds in glandular parts are more 
to be dreaded than the mildnefs of the 
fymptoms which appear at firft would 
lead us to imagine. When fmall glands 
only are divided, they often heal readi- 
ly ; but when any of the larger glands 
are injured, the fyftem is not only apt to 
fuffer from the fecretion for which they 
are intended being impeded, but the 
C 2 fores 

« Vide Treatife on Ulcers, &c, Part II. Sedion VII. 



^a Of Wounds in general. Ch. XXXV-t 

fores which enfue very commonly become 
fungous, and are cicatrifed with diffi- 
culty. 

When any of the larger lymphatic 
veflels are wounded, the cure often proves 
tedious by a conflanc difcharge of a thirfc^ 
limpid fluid, by which the formation of 
a cicatrix is prevented : And when at 
laft a cure is obtained, very troublefome 
fwellings are apt to occur in the under 
part of the limb, owing to. the obdrudioii. 
of the lymph in its pajQage to the heart 
by the newly formed cicatrix. Of this 
every pradlitioner of experience muft 
have feen fome inftances. I have met 
with feveral ; particularly after the ex- 
tirpation of fcirrhous glands whea deep- 
ly feated in the arm-pit. In fuch cafes 
the large lymphatics of the arm are very 
frequently cut, and very obftinate oede- 
matous fwellings of the whole member 
are apt to enfue. 

When a large nerve is completely di- 
vided, the pain attending it will be in- 
confiderable ; but the parts beneath will 

be 



Sea. I. Of Wounds in general. ng 

be deprived both of their fenfibility and 
power of motion, unlefs they are fupplied 
■with fome other branches. But when a 
nerve is only pundlured, the pain which 
takes place is commonly fevere : and this 
is apt to be followed with a high degree 
of inflammation ; fmart fever ; fubfultus 
tendinum ; convulfions ; and even death. 
Thefe violent appearances, however, do 
not often occur in northern climates ; but 
.they frequently happen in warm coun- 
tries, where they are apt to terminate in 
a fymptom which .often proves fatal, the 
locked jaw. 

In wounds of any of the larger blood- 
veffels, our firft obje(5l is to difcover, whe- 
ther the hemorrhagy which enfues pro- 
ceeds from arteries or veins ; for in gene- 
ral no material inconvenience is experien- 
ced from wounds even of thelargeft veins, 
while the utmoft danger is to be dread- 
ed from wounds of the larger arteries. 
If the artery be fo fituated that a ligature 
cannot be put round it, the lofs of blood 
will probably foon prove fatal : and even 
Q 3 where 



30 Of Wounds in general. Ch. XXXVI, 

where the dlfcharge of blood can be ftop^- 
ped with eafe, if the limb has no other 
artery to fnpply it, a mortification is to be 
dreaded. It often happens, indeed, even 
that large arteries are fecured by liga- 
tures without any detriment to the parts 
beneath : But in this cafe there are other 
arteries or anaflomofing branches of fuch 
a fize as to give pafTage to a fufficient 
quantity of blood. 

The fite of a wound is alfo an objeft 
of importance. Thus wounds in the ex- 
tremities, when confined to parts lying 
above any of the hard bones, are not to 
be confidered as fo hazardous as thofe 
which pafs into any of the joints : and in 
other parts of the body, wounds which 
penetrate any of the larger cavities, 
prove always more dangerous than thoie 
which do not run to fuch a depth. 

This will proceed from different caufes. 
The danger will be jncreafed by the 
chance of fome organ of importance be- 
ing diredly injured : By air, and in fome 
pgfes by extraneous bodies, finding accefs 



Sed. L Of Wounds in general 31 

to cavities which nature never meant to 
be expofed: And laftly, by the lodgement 
of matter ; a circumftance which is with 
much difficulty avoided in all wounds 
which penetrate to fuch a depth. 

We have likewife to confidcr, that al- 
though no organ of importance may be 
diredlly wounded in fuch a manner as to 
produce immediate death; yet that much 
danger may arife from a variety of cir- 
cumftances ; and wounds may eventual- 
ly prove mortal which at firfl: were not 
attended with any evident rifk. 

Thus wounds in the lungs, and other 
vifcera, prove fometimes fatal, from con- 
tinuing to difcharge fuch quantities of 
blood for a confiderable time as at lafl: 
deftroy the patient; although at firfl: the 
difcharge might not appear to be of much 
importance. The ftomach, and different 
parts of the alimentary canal, may be in- 
jured in fuch a manner as to terminate; 
in death without exhibiting any immedi- 
ate appearance of danger. The external 
coat of the aorta has been removed by 
C 4 i.h^- 



3? Of Wounds in general. Ch, XXX VI. 

the point of a fmall fword ; and the wound 
has been nearly healed when the patient 
died fuddenly from a rupture of the ar- 
tery : And wounds of the gall bladder, 
or of its excretory du6l ; of the recepta- 
culum chyli ; of the thoracic dudl, and 
fome other vifcera ; may for feveral days 
afford no fufpicion of danger, and yet 
terminate fatally at laft, 

Wounds fometimes prove fatal from 
inflammation fpreading to contiguous 
vifcera, which were not at firft injured; 
and wounds, which have at firfl appeared 
to be of little or no importance, have at 
laft terminated in the wprft manner, mere- 
ly by mifmanagement, either in the ap-r 
plication of dreflings or bandages, or ia 
the condudl of the patient vvith refpedt 
to food, drink, and exercife ; for it is well 
known, that much mifchief has been done 
by improper dreflings, and efpecially by 
too tight bandages : and we likewife 
know, that mifcondudl with refpedl to 
fpod is daily the caufe of wounds goirjg 

wrpngj 



Se£t. I. Of Wounds in General. 33 

wrong, which otherwife would proba- 
bly have done well. 

It thus appears, that a variety of cir- 
cumftances fall to be confidered, to enable 
us to judge of the probable terminationi 
of wounds. In doing this with accura- 
cy, pradlitioners of experience have fre- 
quent opportunities of fhowing their fu- 
periority. This fubjedl ought therefore 
to be confidered as highly important by 
all who wilh to diftinguifh themfelves. 
A minute knowledge of anatomy, a cool 
temper, and a fteady hand, will enable 
any praditioner, even with no great ex- 
perience, to perform many of our moft 
important pperations fuflSciently well : 
And accordingly in different hofpitals, 
we daily meet with good operators ; but 
we do not often find furgeons pofTelTed of 
that knowledge in the prognofis of chi- 
rurgical difeafes which might be expedli- 
ed ; that attention being feldom beftow- 
ed which is ncceJGTary to attain it. 

SECTION 



34 Offtrnple Ch. XXXVI. 

S E C T I O N 11. 
Of the Cure of Simple tncifed Wounds. 

IN the management of wounds of every 
kind, the firfl: obje<fl requiring our 
attention is the hemorrhagy; more efpe- 
cially when it is profufe. The fafety of 
the patient requires it : The alarm which . 
it gives, not only to byflanders, but to 
the practitioner himfelf, renders it necef- 
fary. Nor can the real flate of a wound 
be difcovered with accuracy till the dif- 
charge of blood be checked, 

Hemorrhagies are moft immediately 
flopped by pre (Fare applied to that part 
of the divided artery which is next to the 
heart : This prefTure is made by the tour- 
niquet, when the wound is in any of the 
extremities * ; and by the hands of adift- 
ants, in wounds of the trunk of the body 
or of the head. 

. In 

* Vide Vol. I. Chap. II. 



Sea. II. Inclfed Wounds. 35 

In this manner, if the prefTnre be pro- 
perly applied, almoft any hemorrhagy 
may be ftopped till the wounded veflels 
can be fecured with ligatures ; which we 
have elfewhere (hown to be the fafeft, as 
it is the eafieft method of preventing pa- 
tients with fnch injuries from fufFering *. 
Much indeed has been faid, even of late 
years, of the inconveniences which liga- 
tures are fuppofed to induce : but this 
has proceeded either from the interefted 
views of fome individuals who may have 
wifhed to eftablifh the reputation of dif- 
ferent ftyptic applications ; or from the 
groundlefs fears of young praditioners. 
Where the contiguous nerves, or even 
where much of the furrounding mufcular 
parts, are included in ligatures, fevere 
pain, and other troiiblelbme fymptoms, 
will no doubt be induced ; but this is not 
the fault of the remedy, but of the me- 
thod of ufing it. Indeed this is fo obvi- 
oufly the cafe, that reafoning in the far- 
ther fupport of it does not feem to be 
necelTary ; for every pradtitioner of ex- 
perience 

* Vide Vol. I. Chap. IL 



36 Offtmple Ch. XXXVI. 

perience will admit, that a proper ap- 
plication of the ligature is feldom if ever 
produdlive of any material inconveni- 
ence, and that. we can depend on *it with 
more certainty than on any other remedy 
for putting a ftop to hemorrhagies from 
wounded arteries. 

When treating of the method of ap- 
plying ligatures to arteries, in the firft 
volume of this work, I gave it clearly as 
my opinion, that it may be beft done by 
the tenaculum, an inftrument reprefent- 
ed in Plate 1. fig. i. And after much 
additional experience of its utility, I now 
think it right to fay, that I am more and 
more convinced of its being much fupe- 
rior to the needle ; which cannot be ufed 
without a portion of the contiguous foft 
parts being included in the ligature ; a 
circumftance which in every inflance we 
Ihould endeavour to avoid. Many ima- 
gine that the tenaculum may be ufed 
with fafety in the application of ligatures 
to arteries of a middling fize, while they 
are afraid cf cutting thofe of a fmall fize 

afundera 



Seft. II. Inctfed Wounds. 57 

afunder, if fome of the contiguous cel- 
lular fubftance be not included along with 
them : and in tying the large trunks of 
arteries, they fufpecl that the ligatures 
would be apt to be forced off by the 
ftrong pulfations of thefe vefTels, if they 
were not fupported by being firnaly fixed 
in the contiguous parts. I have not, 
however, had a fingle inflance of obfcr- 
ving that either of thefe objedions to this 
pradlice is well founded. For a num- 
ber of years pafl, I have laid afide the 
needle, for the purpofe of applying liga- 
tures to arteries, almoft entirely; and in 
the courfe of that time, I have employed 
the tenaculum indifcriminately in hemor- 
rhagies from arteries of all fizes. 

Wounded arteries are feldom fo fitua- 
ted as to prevent the hcmorrhagy from 
being (lopped in the manner we have 
mentioned : for when they lie at the bot- 
tom of deep wounds, with narrow con- 
tradled mouths, the wound may common- 
ly be enlarged fo as to admit of their be- 
ing tied with ligatures ; and for the mod 

paFt 



38 Of Simple Ch. XXXVI. 

part it may be done with fafety. Where 
the enlargement of a wounds is not 
clearly necefTary, no perfon of experi- 
ence would advife it ; but the pradice 
is always fafe and proper in hemorrha- 
gies proceeding from arteries lying fo 
deep that ligatures cannot otherwife be 
applied to them. As this pradice, how- 
ever, has been very inadvertently con- 
demned by fome pracTitioners in a gene- 
ral way, from their fuppofing it to be 
rarely if ever necefTary ; a timidity has 
been thereby introduced, which, in va- 
rious inftances, has been the caufe of 
mifchief : Patients have been tormented 
with the application of tight bandages, 
and with the trial of different flyptics, 
which feldom if ever fucceed, when the 
hemorrhagy might hUve been flopped in 
the mod effedual manner by a fmall en- 
largement of the wound : Nay, many 
limbs have been amputated from the fame 
caufe, which might eafily have been faved ; 
particularly in cafes of compound frac- 
ture, where a hemorrhagy, proceeding 

from 



Sed. II. Incifed Wounds. 39 

from a deep-feated artery which cannot 
be eafily tied, is too frequently consider- 
ed as a fufficient reafon for removing the 
limb. From particular circumftances, in 
a few cafes of compound fra(flure, it may 
happen that hemorrhagies cannot be 
flopped without laying the injured parts 
fo extenfively open, as might induce 
more hazard than amputation itfelf. This, 
however, is a very rare occurrence ; 
and it will fcldom take place where the 
cafe has been properly treated from the 
beginning. 

When the injured artery runs in the 
fubftance of a bone, no ligature, it is 
evident, can be applied to it; and, there- 
fore, in fuch a cafe, enlarging the wound 
could not be attended with much advan- 
tage. But arteries in this fituation are 
never fo large as to lead us to be much 
afraid of any hemorrhagies that may 
proceed from them ; nor does it often 
happen that they continue to bleed long 
after they have been completely divided. 
An artery thus fituated, being merely 

wounded. 



40 Offimpls ^ Ch. XXXVL 

wounded, may difcharge a great deal of 
blood ; but I have met with different in- 
flances of the hemorrhagy flopping al- 
moft immediately on the veffel being cut 
acrofs. Authors indeed have faid, that 
the utmoft danger has been induced by 
arteries furrounded with bone being 
wounded ; nay, that death itfelf has hap- 
pened from this caufe, owing to the im- 
poflibility of including them in ligatures. 
I am convinced, however, that it is a 
partial divifion only of fuch arteries that 
will ever produce hemorrhagies of any 
importance ; for they are always fmall, 
and they never adhere fo firmly to the 
furrounding bone as to be prevented from 
contradling on being freely divided. 

"Where the difcharge of blood proceeds 
from large vefTels, the means we have 
mentioned are the mofl efFedtual for put- 
ting a flop to it. But when it occurs 
from an infinite number of fmall arteries 
over the whole furface of the wound, 
other remedies muft be employed. We 
mud refer, however, to a former chapter 

of 



Sea. II. Iiicifed Wounds. 



41 



of this work, where this fubje(fl was more 
fully coafidered *. 

The hemorrhagy being flopped, the 
next objedl requiring our attention is the 
removal of any extraneous body that may 
have been admitted : and where fuch fub- 
ftances are not deeply feated, this is al- 
ways done both with moft eafe and fafe- 
ty with the fingers alone ; for when for- 
ceps and other inftruments are employ- 
ed, we can fcarcely fail to injure the con- 
tiguous parts. 

The examination of wounds, with a 
view to difcover extraneous bodies, ought 
to be made with much caution and deli- 
cacy ; for handling the parts roughly 
gives unneceffary pain, and is apt to in- 
duce a degree of inflammation, which 
often proves hazardous. 

But although it is always proper to ac- 
qomplifli the removal of extraneous bo- 
dies with as little pain to the patient as 
poffible; yet wherever we have any cer- 
tainty of bodies of this kind being lod- 

*VideVoI.I.Chap.fI.SeaionII. 



42 Offimple Ch. XXXV!. 

ged, we ought by all means to proceed 
with firmnefs, in the firft place, in difco' 
vering their ficuation, and afterwards in 
removing them, excepting in a few par- 
ticular cafes where this cannot be done 
without much rifk of injuring parts of 
real imparlance to life. In fuch cafes 
the judgment of the praditioner muft 
decide between the danger that may 
probably enfue from the extraneous bo- 
dy being allowed to remain, and that 
which may arife from his proceeding to 
remove it immediately. 

Modern authors in general ftridly for- 
bid much afliduity in the removal of bo- 
dies of this kind : for they very properly 
obferv'e, that in former times much mif- 
chief was done by exploring wounds with 
more exadnefs than was requifitej by 
which unneceflary pain was induced, and 
cures rendered more tedious than they 
otherwife would have been. 

But in this matter the moderns feem to 
have gone from one extreme to another : 
ior although much handUng of fores, and 



St;6l. II-. Incifed Wounds. 4j 

a free ufe of probes, forceps, and other 
inftrtwnents, are fekiom neceflary, it is 
equally true, that by allowing extraneous 
bodies, which might have been removed 
at firfl, to remain in wounds, much fu- 
ture pain and inflammation have been 
occafioned. 

In fupport of the pradlice we are told, 
that various cafes are on record of extra- 
neous bodies continuing to lodge in dif- 
ferent parts of the body without any in- 
convenience; that this will commonly 
happen when the fubftance is not of a 
flimulating nature; and when it is of 
fuch a form or texture as to induce pain, 
that will foon excite fuch a plentiful 
fuppuration as will quickly throw it 
out in a much more eafy manner than 
if it had been removed at firft. In an- 
fwer to this, I fliall obferve, that where 
extraneous bodies in' wounds cannot be 
removed without giving the patient a 
great deal of pain ; and efpecially where 
there is any rifle of large contiguous 
blood-veflTels being wounded by it ; we 
D 2 ought 



44 Offmple Ch. XXXVI. ' 

ought by no means to attempt their re- 
moval. In fuch cafes we ought certain- 
ly to truft to the fubfequent fuppuration 
for throwing them cut : Bvit they ought 
always to be taken cut immediately, 
when it can be done with tolerable eafe, 
or without injuring any parts of import- 
ance. In this way a, more expeditious 
cure is obtained, and we accomplifh our 
purpofe in an eafier manner, than could 
be done in any future flage of the fore. 
For in a recent wound, while no inflam- 
mation or teniion takes place, the conti- 
guous parts eafily flretch and yield to the 
extradion of any fubftance that may be 
lodged in them, if it be not of an angu- 
lar form, and if the operation, inftead of 
being performed quickly, be done with 
flownefs and caution : whereas, when the 
contiguous parts become ftiff and pain- 
ful, w^hich they always do in the courfe 
of a fliort time, any fubftance lodged in * 
them is removed with much pain and dif- 
ficulty : for even after a free fuppuration 
has taken place, akliough the parts will 

be 



Se£l. II. Inc'ifcd Wounds. 45 

be confidercibly relaxed, yet ftill'they will 
be more fliff and tenfe than they were at 
firft ; and the opening through which the 
fubftance is to be extracted will likewife 
be much ciiminilhed. 

We gain another very material advan- 
tage by the immediate removal of extra- 
neous bodies from wounds. While a fore 
is lecent, almoll every patient will allow 
every thing to be done which the practi- 
tioner in attenadnce may think necef- 
fary ; but they frequently refufe, in fu- 
ture (lages of the fore, to fubmit to any 
thing befides the ufual dreflings. 

It may be remarked in this place, that 
of the extraneous bodies that are apt to be 
lodged in wounds, fome are more harmlefs 
than others. A prudent pradlitioner will 
therefore be more or lefs anxious in at- 
tempting to remove them. Thus we all 
know, that a lead-ball may be lodged very 
deeply, for a great length of time, with- 
out being produdive either of pain or in- 
convenience ; while a fpllnter of wood, 
glafs, or iron, or even a bit of cloth, 
D 3 will 



4^ Offimple Ch. XXXVI, 

will often create a great degree of iinea-^ 
finefs. When therefore it is known that 
a lead-ball is the only fubftance that is 
lodged, if it cannot be eafily removed, 
v;e have at leaft the fatisfaclion of being; 
affnred that it will not probably do much 
harm. We will therefore allow it to re- 
main, either till it be.loofened by a plen- 
tiful fuppuration, or till fome future per 
rlod, when it may perhaps be difcovered 
in a different fituation, fo as to be taken 
out with fafety at a counter-opening: 
While, on the other handj, when fuch fub- 
ftances are lodged in wounds aswillpro'- 
bably excite much irritation and pain, it 
will be much for the intereft of the pa- 
tient, and will be the means of preventr 
jng much perplexity and trouble to the 
furgeon, to have them removed as foon 
as poifible after the injury is infli(5led. 

We iiave obferved above, that in remo- 
ving extraneous bodies from wounds, it 
fliould be done with the fingers alone, 
rather-than witii forceps. Some few ex- 
peptions may occur to this, which we (liall 

afterwards 



Seft. IT. hicifed Wounds. 47 

afterwards have occafion to mention. 
But luhflances are fometlmes lodged in 
wounds that cannot be eafily taken out 
either with the fingers or forceps. This 
is particularly the cafe with fand, duft, 
and fmall pieces of glafs. TheJe are beft 
removed by bathing the parts in warm 
water, or by pouring water upon them ; 
iqueezing it gently from a fponge, or in- 
jeding it flowly with a fyringe. 

In performing even this very fimple 
operation of wafliing a wound, as well as 
in extrading foreign fubftances either 
with the forceps or any other way, it 
is proper to obferve, that much advantage 
may be derived from placing the patienc 
in fuch a pofture as tends moft effedual- 
ly to relax the injured parts, fo as to ob- 
tain as wide a feparation as poffible of the 
lips of the wound. I have feen different 
inftances where, from want of attention 
to this circumllance, patients have fuffer- 
ed much unneceffary pain ; where, after 
various trials, the praditloner has been 
obliged to dcfifl without accomplifliino- 
D 4 his 



'4^ Offimple Ch. XXXVI. 

KIs object ; and where another pracflition- 
er has proved at once fuccefsful, merely 
by putting the wounded parts in a relax- 
ed pofition. 

After paying due attention to the cir- 
cumftances refpe<5ling extraneous bodies 
lodged in wounds, our next obje<fl is the 
condu6t of the cure. 

In incifed wounds, a feparation of the 
parts that have been divided takes place ; 
and as every wound proves a caufe of ir- 
ritation, the feparation which at firft ap- 
pears continues for fome time to increafe, 
merely by the contraiStile power of the in- 
jured mufcles. In the ufual way of cover- 
ing wounds with lint, or with pledgits of 
ointments, and where the parts have not 
been previoufly drawn together and re- 
tained in their fituation, an efFufion of a 
ferous fluid foon takes place from the 
great number of fmali veflels that have 
been cut. This is afterwards converted 
into purulent matter : in a fliort* time the 
fore is found to be covered with an inr- 
§riite number of fmall fprouts or gra- 
nulations J 



Sedi. II. Incifed Wounds. 49 

nulations ; and thefe having advanced to 
a certain extent, a dry pellicle of fcarf- 
Ikin, termed a Cicatrix, forms over the 
whole extent of the w^ound, and thus the 
cure 13 completed. 

This is the manner in which the heal- 
ing of wounds is efFedled, when nature is 
not affifted by art, or when her opera- 
tions are only promoted by proper cover- 
ings, and protedlion being given to fuch 
parts as are injured. But although, in 
fome cafes, this is our only refource ; and 
although even in this way pradlitioners 
have it always in their power to forward 
the cure of fores ; yet it is liable to ma- 
ny very important objedlions, which may 
be obviated by a different treatment. 

When a wound is healed in this man- 
ner, if the parts which have been divided 
have feparated to any confiderable extent, 
the fuppuration which enfues will be plen- 
tiful J by which, if the conftitution is 
weak, the pati-ent is apt to be materially 
injured. In extenfive fores, this method 
of cure is always tedious : When deep 

mufcular 



so Offi7npk Ch. XXXVI. 

mufcular parts are injured, the motion of 
the contiguous joints is apt to be affeded, 
by the divided parts healing when too far 
feparated from each other. And the cica- 
trix of a large wound, when cured in this 
manner, is always ftifF, unfeemly, and dif- 
agreeable : nor is it poffefled of that 
ftrength and firmnefs which the parts 
beneath require for their protecflion. 

Patients, however, are feldom under 
the dilagreeable neceflity of fubmitting 
to thefe inconveniences : for in general, 
wounds may be cured in a much more 
eafy as well as in a more agreeable man- 
ner. We know from experience, that 
two inflamed furfaces of an animal body, 
when kept in contad, will foon adhere 
together. This was probably at firft, 
pointed out by accident ; but practition- 
ers now derive much advantage from it 
in various operations, as well as in the 
treatment of accidental wounds. By 
drawing fuch parts as have been divided 
into contadl with each other ; and efpe- 
cially by taking care to have them all as 

com- 



Sedl. II. Inct/ed Wounds. 51 

completely covered as poflible with the 
cutis vera< very extenfive wounds are of- 
ten quickly cured ; the power of moving 
and of ufing limbs with freedom is often 
preferved which othervvife would be loft ; 
the Tear or mark which remains is fel- 
dom of any importance ; and the wound- 
ed parts have the advantage of being fuf- 
ficiently protected. 

The fadl has been long known with 
refpe£t to this point ; for there is nothing 
more certain, than that parts recently di- 
vided, \yill unite firmly together, if they 
be kept in conta<5t for a fufficient length 
of time. The caufe, however, of this 
phenomenon has not hitherto been ren- 
dered clear. The prevailing idea is, that 
it proceeds from a diredt inolculation 
or jundlion of the different parts that 
have been divided ; and that thofe parts 
only will adhere together which were 
formerly united. Thus it is imagined 
in the healing of wounds in this man- 
ner, that a divided artery on one fide 
of a cut muft be made to adhere dire611y 

■' with 



52 Offimple Ch. XXXVI. 

with its fellow on the oppofite fide ; that 
veins niufl: unite with veins; mufcular 
fibres with fibres of a fiinilar nature, &c. 
But ahhough it is necefTary in pradlice to 
keep this idea fo far in view, as to place 
parts that are to be healed as exadly op- 
pofice to each other as pofTible ; yet this 
proceeds more from a requifite atten- 
tion to fymmetry and neatnefs in the 
external parts after the cure, than from 
any other caufe : for it is certain, that 
no fuch exadnefs is required for the 
mere adhefion of the divided parts ; and 
whoever doubts of the fad may with 
little difficulty prove it experimental- 
ly. A membrane may be made to ad- 
here to a bone ; and the divided end of 
an artery or a vein will unite with al- 
moft any fubftance with which it is kept 
in contadl. 

It is indeed true, that blood circulates 
through the cicatrix of a wound j a fad 
which few will dcubt, and which proba- 
bly gave rife to the opinion we are now 
eonfidering. But we have reafon to be- 
lieve 



Se£t. II. Incifed Wounds. 53 

lieve that this circulation does not take 
place immediately on the ft)rmation of a 
cicatrix. It feems rather to be an after- 
procefs of nature, and is evidently ac- 
complilhcd by an infinite number of 
Imall vaficular fprouts or newly created 
blood- ve dels, which proceed from the 
larger arteries and veins on each fide of 
the wound, and inofculate with each 
other, fo as to give a fufficient circula- 
tion in the parts through which they 
pafs. At lead I have found, in different 
inftances, on examining the cicatrix of 
a large wound, that it was always very 
vafcular ; and I conclude that it happens 
fromi a new formation of fmall blood- 
vefTels, as the divided extremity of eve- 
ry blood-velTel, whether artery or vein^ 
when of fuch a fi^e as to be eafily dittin- 
guifhed, is always fhut, and even oblite- 
rated for a certain fpace, from the point 
where the injury happened, in the fame 
maniier as in arteries that are tied with 
ligatures, in cafes of amputation and o- 
ther capital operations. And if this hap- 
pens 



54 , ' Of Simple Ch. XXXVL 

pens in vefTels of a large fize, there is 
reafon to fuppofe that it does fo in thofe 
that are fmaller. 

In confirmation of this opinion, we 
may obferve, that a circulation of blood 
becwixt adhering furfaces takes place 
where inofculatioa of the kind in ques- 
tion can never occur, from no previous 
divifion of blood-veffels having been 
made. Thus, when the fkin of two con- 
tiguous fingers or toes becomes raw or 
tender, without any blood-veffels being 
injured, it is difficult to prevent them 
from adhering ; and when they do ad- 
here, a free circulation is afterwards 
found to taljie place between them. Other 
inftances might be adduced ; but I no- 
tice this one, as it is not unfrequent, and 
as it is perfectly applicable to the pre- 
fent queftion. 

I therefore conclude, that wounds cu- 
red in this way are healed in the fame 
manner as adhefion is produced between 
inflamed furfaces, namely, by exfudation 
of the glutinous part of the blood from 

the 



Scfl:. II. Incifed Wounds. ^'^ 

the extremities of the divided velTels ; 
which in the firll place retains the parts 
together, and afterwards ferves to fup- 
port the new formation of fmall blood- 
vefTels, which nature puts forth as a far- 
ther and more certain means of reten- 
tion. 

I have entered into this phyfiological 
difcuflion, imagining that it tends to efta- 
blifh a material point in pradice. It has 
commonly been fuppofed, that the fpace 
of twelve, fourteen, or fifteen days, is 
neceffary for the complete adhefion of 
divided parts : a fuppofition which pro- 
ceeds upon the idea that this adhefion 
is formed folely by the inofculation of 
blood-veflfels. But if agglutination alone 
is necelfary, in the firft inftance, to ac- 
complifh this adhefion, it is evident that 
it muft be efFedled fooner. According- 
ly, I have uniformly found divided parts 
adhering firmly about the fifth day; 
and have known the bandages acciden- 
tally removed from wounds on the fe- 
cond and third days, without any fepa- 

ration 



56 Of Simple Ch. XXXVI. 

ration of the parts newly united being 
the confequence. From this it appears, 
that a fhorter application of the ufual 
means of retention will anfwer than is 
commonly pradlifed. Surgeons term this 
treatment of fores, Healing by the Firft 
Intention ; and as it is in every refpecS 
the mofl: defirable method of cure, it 
fhould always be followed when pradli- 
cable. 

In other varieties of wounds, different 
reafons often occur to prevent us from 
curing them in this manner. Thefe we 
ihall afterwards have occafion to men- 
tion. But in the fimple incifed wound, 
where the injury has been inflidled with 
a clean-cutting inftrument, without pro- 
jducing pun6lure, laceration, or contufion, 
the only objedion that can occur to it, 
is our not being able to draw the divided 
parts into contadl, and to retain them in 
that lituation till they adhere together. 
This, however, will feldom happen, un- 
lefs a lofs of fubftance takes place to a 
conliderable degree. Where a large por- 
tion 



Seft. II. Incifed Woimds: 57 

tion of fkin, wiili the mufcles beneath, 
has been entirely cut oiu, it may in fome 
cafes be impoffible to bring the retra<fl- 
ed edges of the wound together; but we 
may always make them approach fo as 
to diminifli the fize of the fore, and may 
thus have it in our power in every in- 
flance to forward the cure. In deep 
tranfverfe wounds, even where no fub- 
(lance is loft, the retracflion is often fp 
great, as to render this pracftice fomewhat 
difficult : But by placing the injured part 
in that fituation which tends moft effec- 
tually to relax the divided mufcles, we 
may effecft our purpofe almoft in every 
inftance. It is indeed furprifing to fee 
how completely divided parts will b^ 
made to approach, which, while the muG- 
cles were upon the ftretch, were fepara- 
ted to a confiderable diftance from each, 
other. We fhould not therefore defpair 
too foon ; for even in the worft cafes we 
feldom fail by due perfeverance to pro- 
duce fome very etFential advantage. 
When it is found that the divided 
Vol. V. E parts 



58 Offimple Ch. XXXVI. 

parts may be drawn together, we have 
next to fix upon the bed and eafieft me- 
thod of retaining them in this fituation ' 
during the cure. There are various 
means propofed for this y namely ban- 
dages of different kinds, adhefive pla- 
flers, and futures. 

The fides of wounds of a longitudinal 
^ireEWon, fituaied in any of the extremi- 
ties, and of fome wounds of the head,, 
may be retained by the uniting bandage. 
But it fcldom anfwers in the trunk of the 
body ; nor can it ever prove ufeful in 
wounds, either in the legs or arms, of 
a tranfverfe dire^f ion : And even where 
there is reafon to imagine that it wilt 
anfwer fufficiently well for retaining 
the fides of the wound in conta(5l ; yet 
we ought never to truft to it entirely ; 
for we cannot depend upon it with any 
certainty for preferving the fkin fmooth 
and equal ; a circumflance of much im- 
portance in the cure. 

The eafieil method of retaining the fkin 
exactly in its fituation, is by means of 

adhefjve 



Sedt. II. Incifed Wounds* 59 

adiiefive plaflers applied in the manner 
reprelented in Plate LXVII. In fome 
cafes plafters alone will prove fufficient ; 
but when much retradlion is exped:ed^ 
the uniting bandage fhould be applied 
over them whenever the diredlion of the 
wound renders it admiffible. 

Many pracftitioners, in every inftance 
of wound, prefer adhefive plafters to the 
ufe of futures ; but it is in particular 
cafes only that this preference is proper, 
Adhefive plafters may be ufed with ad- 
vantage in fuperficial wounds that do noc 
penetrate much deeper than the cellular 
membrane ; and where there is fuch a 
lofs of fubftance as prevents the fides of 
a wound from being drawn clofe toge- 
ther, they may be employed for the pur- 
pofe of retaining the retracted parts as 
near to each other as they can be eafily 
brought. But in all wounds that pene- 
trate to any confiderable depth, and when 
their edges can be drawn into contact, 
the twilled fiature is by much the moft 
cffedual means of retaining them. For 
E 2 a 



6o Of Simple Ch. XXXVL 

a defcription of this and other futures, 
we muft refer to Volume I. Chapter I. 
The common interrupted future is indeed 
more frequently employed than the o- 
ther ; but it does not fupport the parts 
with fuch certainty ; the ligatures are 
more apt to tear or cut out the parts 
which they furround; and they frequent- 
ly leave difagreeable marks. 

On this fuhjecft it is the common opi- 
nion, that adhefive plafters and futures 
are admilfible only in the recent ftate of 
wounds. But however defirable it may 
be, for various reafons, to have the ap- 
plication of either made as early as pof- 
fible ; yet where they have been ne- 
gle^ed at firft, they may be employed 
with advantage during any ftage of the 
fore : for we are wrong in fuppofing, as 
is commonly done, that wounded parts 
will not adhere when in a ftate of puru- 
lency. I have repeatedly treated in this 
manner, fores of two, three, and four 
weeks duration, and always with advan- 
tage : Infomuch, that I believe the prac- 
tice 



Se6l. II. Incifed Wounds. 6i 

tice will very commonly fucceed in every 
ftage of a fore when the retraced edges 
can be brought together. 

Whether we employ adhefive plaflers 
or futures, we fhould be very attentive in 
fupporting the parts, as far as it can be 
done, by the pofture of the patient ; for 
if this be negledled, futures of every kind 
will yield fo as not to anfwer the purpofe : 
And along with this, when plafters are 
"ufed, a farther advantage, as we have al- 
ready obferved, may be derived from a 
proper application of the uniting ban- 
dage ; but for the reafons given in the 
chapter on Sutures, and again when 
treating of the Hare-lip in Chap, XXIX. 
Vol. IV. neither this nor any other ban- 
dage can with propriety be employed with 
the twifted future. 

When a wound is treated in this man- 
ner, as foon as the retradled edges are 
drawn together and properly fupported, 
whether by plafters or futures, no other 
dreffings are neceflary, excepting fome 
thin covering of foft lint to protedl the 
parts beneath from cold; and with a 
E 3 view 



62 Offtmple Ch. XXXVI. 

view to prevent, as much as poflihle any 
accefs to air, the lint (liould be fprcad 
either with fome unctuous fubftance, or 
with mucilage of any inoffenfive gum. 

This being done, the patient fhoulcl be 
enjoined to preferve the injured parts in 
the pollure that is judged mofl favour- 
able; and care fhould be taken to put 
him under proper regulations with re- 
fpecft to diet. Jf he is low and emacia-? 
ted, he may with propriety have a fmall 
allowance of light nouriQiing food ; but 
if he is in any degree plethoric, or liable 
to inflammatory afFedions, if the wound 
is of any conliderable extent, a ftrirt an- 
tiphlogiflic courfe will be abfolutely ncr 
cefTary : for although inflammation to a 
certain extent be highly necefTary for the 
cure of the wound; yet a prudent prac- 
titioner will always guard againfl excels 
of Inflamrnation, as prodijdlive of much 
mifchief. 

In open wounds, one of the mofl ef- 
fecl-lual applications for removing exr 
|:reme degrees of inflammation, is warm 
pmollient cataplafms ; but as they tend 

to 



Seel. II. Incifcd Wounds, 6^ 

to induce the formation of matter, and 
as this would be direcftly oppofite to our 
views in adopting the mode of cure we 
are now confidering, it is evident in fuch 
circumftances that they are altogether 
inapplicable. But although warm emol- 
lients cannot with propriety be employ- 
ed ; yet much advantage may be derived 
from a prudent ufe of any cold emollient 
loil or unguent. When the attending 
fymptomsof pain and inflammation con- 
tinue moderate, the dreflings fliould ne- 
ver be removed till the cure be comple- 
ted ; but whenever the pain becomes fe- 
vere, as it would probably, if neglecfled, 
terminate in a confiderable degree of in- 
flammation, by which our intention might 
be fruftrated, the dreflings fliould be im- 
mediately taken away, fo as to admit of 
the pained parts being freely rubbed or 
even bathed with an emollient. By re- 
peated applications of this kind, I have 
£cc\\ different inflances of verv difl:refling 
degrees of pain being much alleviated, 
and of the contiguous parts being £o 
E 4 much 



04 Offimpk Ch. XXXVI. 

iiinch relaxed, as to admit cf the cure by 
adhelion going on without; internipiion. 
In feme cafes, however, we are under the 
neceffity of cmplo5'ing other means; and 
of thefe themoft effettual are opiates and 
blood-letting, particularly local blood- 
letting by means of leeches ; which of.- 
ten proves effetftual in removing pain and 
inflammation, when every other applica-. 
tion has been tried in vain. 

In general, a continuation of thefe 
rneans will anfwer the purpofe : but it 
Ibmetimes happens, that notwithftand- 
ing all our endeavours, the pain and in- 
;flammation incrcafe, and the tenfion of 
the wounded parts becoming more confi- 
derable, the plaflers and ligatures with 
which they have been kept together 
inufl: be taken away, otherwife they will 
do mifchief ; and at lafl: will yield, fo 
as to be produftive cf no" advantage 
M^hatcver. In ftich circumftances it is 
better to remove them at once; and for 
the moft part this will give the patient 
immedi3te relief: the pain and tenfion 

will 



Sed. II. Incifed Wounds. 6^ 

will foon difappear ; and a cure will be 
accomplilhed in the ordinary way : for 
it might prove hazardous to attempt the 
fame method of treatment again. 

By thefe means the bad confequences 
now mentioned may be obviated : But it 
is proper to remark, that fymptoms of 
this kind are not frequent. In. gene- 
ral, the cure goes on without interrup- 
tion ; and where this is the cafe, our 
views are completed as foon as there 
is reafon to fuppofe that a firm adhefion 
has taken place between the edges of the 
wound. We have already remarked, that 
this procefs is commonly effedled in a 
ihorter time than is ufually imagined. 
In fuperficial wounds, the ligatures, or 
other means of retenfion, may be remo- 
ved fooner ; but even in deep extenfive 
wounds, when the habit of body is found, 
they may with fafety be taken away on 
the fifth or fixth day : for by this time 
all the advantage that can be derived 
from them will be gained j while much 
inconvenience, and fome mifchief, may 

arife 



^66 . Offimpie Ch. XXXVI. 

arlfe from their being allowed to remain 
longer. 

We have already mentioned many of 
the advantages wliich refult from this 
method of curing wounds. Indeed they 
are fo great, that there (liould be no he- 
fitation in attempting it almolT: in every 
inftance : for even when it fails, we are 
certain that any troublefome lymptom 
that may be induced by it, will be re- 
moved by due attention to the means wc 
have mentioned ; while much time will 
be gained when it fucceeds. Two ob- 
jeftions are commonly made to this mode 
of treatment, which we lliall fliortly men- 
tion. It is faid, that the ligatures with 
which it is often ncceifary to fecure the 
arteries, will ad: as extraneous bodies, 
and prevent the fides of the wound from 
uniting. And it is likewife obferved, 
that in the courfe of the cure matter is 
apt to form, from the lodging of which, 
troublefome finufes are produced. Nei- 
ther of thefe objecftions, however, is in 
any degree well founded ; at lead, I have 

never 



Sect. II. Incifed Wounds. 6y 

never met with a fingle inflance of either 
of them. It feldom happens that more 
than one or two arteries in any wound 
are fo large as to require to be tied : but 
I know from experience, that wounds 
may be cured by drawing their edges to- 
gether, even where a coniiderable num- 
ber of arteries have been fecured by li- 
gatures: for the threads occupy very 
little fpace ; and when they are applied 
with the tenaculum, which ought always 
to be done, they are eafily removed with- 
out any difturbance being given to the 
other parts of the wound. And again, 
with refpecfl to finufes being apt to form 
from this method of treatment, if the 
edges of a wound be only drawn toge- 
ther above, a cavity will thus be formed 
beneath, where matter will no doubt be 
apt to lodge ; but this fhould not be at- 
tributed to the method of cure, but to 
the mode of putting it in practice : for 
in every wound which ought to be treat- 
ed in this manner, the whole of the fides 
pr edges may be drawn together from top 

to 



68 Offtmple Ch. XXXVI. 

to bottom; and by this means the for- 
mation of finufes prevented. 

We have now to fpeak of thofe wounds 
■which do not admit of this mode of treat- 
ment. When the edges of a cut cannot 
be drawn together, after the hemorrhagy 
is flopped and extraneous bodies remo- 
ved, we find by experience, that the moft 
efFedlual afliftance we can afford, is to 
promote as much as poffible the forma- 
tion of matter : for the fad is undoubt- 
ed, in every wound of this kind, that a 
free fuppuration proves the moft effedlual 
relief to every fymptom ; at the fame time 
that it appears to be fo materially con- 
ne6led with the cure, that the healing 
procefs never begins till the fore is cover- 
ed with good pus ; a circumftance by no 
means difficult to account for. The cure 
of fores healed in this manner, is fo far 
effedled by nature alone, that although 
fome advantage may be derived from art, 
yet the chief objedl of practitioners is to 
remove fuch impediments as might tend 
to obftrudl the operations of nature, and 

to 



Se£t. II. Incifed Wounds. 69 

to proted the injured parts till the cica- 
trix becomes fufficiently firm. Now, as 
we know that a fore will never be cover- 
ed with granulations, or be cicatrifed, as 
long as it is very painful ; and as nothing 
with which we are acquainted proves 
fo mild an application to wounds as pus, 
we may conclude, that it is chiefly ufeful 
by preferving the injured parts in that 
eafy, pleafant Hate, which feems to be in- 
difpenfably necelTary for the cure of every 
fore. It iliould therefore be our firft ob- 
jeft, in treating fores in this manner, to 
forward the formation of pus as quickly 
as poflible ; and the mod effectual me- 
thod of doing it is, by treating every 
wound In the fame manner as we do a 
common phlegmon ; namely, by a free 
ufe of warm emollient poultices and fo- 
mentations. In the firfl: place^ the parts 
ought to be immediately covered as com- 
pletely as polfible, fo that they may be 
protected effectually from the admiflion 
of air. When the pain which occurs is 
cxceffive, poultices may be diredly ap- 
plied, 



70 Of Simple Ch. XXXVI. 

plied, as being the fureft means of relie- 
ving it : bi!t, when the piiin is moderate, 
it is better to dehiy the ufe of emollients 
for a day or two ; for as pus cannot be 
produced till a ferous efFuiion has firft ta- 
ken place, and as we know that fome de- 
gree of inflammation is required for ef- 
fecting this, when the pain and lenfion 
in wounds are inconfiderable, an imme- 
diate application of poultices is apt to do 
harm, either by preventing altogether, or 
by retarding and rendering too languid 
that inflammatory affection which is fo 
highly necelTary for the cure. But in 
every inftance of wounds of any confi- 
derable extent, remedies of this kind 
prove always ufeful after the firft two or 
three days have elapfed : for by this time 
a fufficient degree of inflammation has 
commonly taken place for effet^ling the 
wifhed for efFufion ; and we have elfe- 
where had various opportunities of fliow- 
ing, that in no way whatever can this be 
fo readily converted into purulent mat- 
ter as by a free application of heat ; fo 

that 



Sed:. II. Ind/ed Wounds. 71 

that whenever this rernedy is judged to 
be proper, it fliould be ufed to the fame 
extent as we commonly find to be necef- 
fary in every cafe of abfcefs. 

It is proper, howevfr, to remark, that 
fome caution is required in the ufe of this 
remedy : for although heat, whether con- 
veyed by means of poultices or fomen- 
tations, is perhaps the mofl. ufeful appli- 
cation in the ftage of wound we are now 
confidering ; yet a long continuance of 
it is very apt to do mifchief, as we have 
daily opportunities of obferving where 
it is employed by thofe who do not con- 
fider upon what principles it a(fls in pro- 
ving ferviceable. When the purpofe we 
have mentioned is gained, namely, a free 
and kindly fuppu ration, as it is for this only 
that poultices are ufed,theyfhould now be 
laidafide: for when continued longer, they 
almoft conftantly do harm, by relaxing 
the parts to which they are applied too 
much ; by which they are apt to become 
pale, foft, and fpongy, inftead of being of 
a healthy red colour, and of a confider- 

able 



72 Of Simple Ch. XXXVI. 

able degree of firmnefs. Nay, they are 
at laft often produtflive of the very con- 
trary efFeft for which they are employ- 
ed : for although much inflammation 
proves always hurtful in the cure of 
wounds, yet in fome degree it is in every 
cafe necelTary. Now, by continuing the 
life of warm emollients too long, this fa- 
lutary degree of inflammation is fo en- 
tirely carried off, that the matter be- 
comes thin and in too great quantities. 
And thus troublefome vitiated fores are 
produced, which a different management 
might have prevented. The period at 
which the ufe of poultices and other 
warm applications (liould be laid afide, 
muft be determined in every cafe by the 
judgment of the pradlitioner ; but this 
general rule may be fafely adopted. That 
they may at all times be peril fled in as 
long as much pain and inflammation con- 
tinue; but thefe fymptoms becoming mo- 
derate, the difcharge being good, and 
the furface of the wound covered with 
granulations of a healthy appearance, 

thev 



Sed. 11. Incifed Wounds. 73 

they QioLild now be laid afide. In this 
flate of a fore, all the advantages are 
gained which poultices can produce ; and 
a longer continuance of them might oc- 
cafion fome of the inconveniences we 
have mentioned. 

"With refpect to the mofl: proper drefs- 
ings for wounds, as we have confidered. 
this fubjeft elfewhere*, it will not be ne- 
celTary to treat of it at prefent with that 
minutenefs which otherwife would have 
been proper. 

We have already had different oppor- 
tunities of remarking, that a certain de- 
gree of inflammation is neceflary in the 
cure of every fore ; but as this very rare- 
ly proves deficient, and as there is more 
to be dreaded from its proceeding too 
far, efpecially in the firft ftages of large 
wounds, the mildeft dreflings only fhould 
be employed. During the progrefs of 
the cure, much advantage indeed may 
fometimes be derived from the applica- 
VoL. V. F tion 

* Treatlfe on Ulcers, &c. Part II. 



74 Offtmpk Ch. XXXVf. 

tion of dreHlngs of an Irritating, or even 
of an efcharotic nature. Tiiis, however, is 
only the cafe when a wound has advan- 
ced to the ftate of an ulcer. While a 
wound is yet recent, there cannot be a 
doubt of the mildeft applications being 
the beft. In this country, foft dry lint 
is commonly employed, and by Ibme^ 
pieces of foft fponge are recommended ; 
and itmuft be admitted, that they anfwer 
much better than any of the irritating 
balfams which till of late were fo uni- 
verfaily ufed, and which in mofl: parts of 
Europe are ftill continued : for jt was in 
Britain that mild dreffings to wounds were 
firft introduced ; and it is in this coun- 
try only where even yet they have been 
generally received. But although dry 
lint is an eafy mild application when com- 
pared with many others, yet it is cer- 
tain that it always creates fome degree 
of pain and irritation on being firft ap- 
plied ; and it is apt to adhere to the edges 
of a wound, fo as to caufe fome pain and 
difficulty on being removed. With a 

view 



Sect. II. Incifed Wounds. ^5 

view to prevent thefe inconveniences, it 
ihould be thinly fpread with fome mild 
emollient ointment ; fuch as Goulard's 
cerate, or the Unguentum Simplex of the 
Edinburgh Difpenfatory. By this means , 
it gives no pain in the application, and 
it is removed with eafe, at the fame time 
that it ferves more effedlually than dry 
materials to prevent the air from finding 
accefs to the fore. As dry lint, however, 
has long been very generally employed 
in this country, any innovation will not 
be readily admitted ; but what I have ad- 
vifed being the refult of a good deal of 
experience, I can with confidence recom-* 
mend it. 

A piece of foft lint, fpread with any 
ointment of this kind, being laid over 
the wound, a bolder of fine tow fhould 
be applied above it for the purpofe of 
keeping the parts warm, as well as for 
abforbing any matter that may be dif- 
charged ; and this being covered with a 
comprefs of old foft linen, the whole 
fliould be retained by a bandage of fine 
F 2 flannel. 



76 Of Simple Ch. XXXVI. 

flannel, which is preferable to linen, in 
fo far as it is more agreeable to the feel- 
ings of the patient, and as it yields to any 
accidental fwelling or tumefadlion of the 
neighbouring parts : whereas linen, pof- 
feffing little or no elafticity,' is very apt 
to do mifchief, by remaining fliff and 
immoveable, notwithftanding any fwel- 
ling that may enfue. 

Pradicioners are not agreed refpeding 
the time at which the firft dreflings of 
fores fhould be removed j and nothing 
deciflve can be faid on the fubjecft, as in 
fome meafure it muft be directed by the 
circumftances of every cafe. This ge- 
neral rule, however, may be properly a- 
dopted, that a fore fliould always be dref- 
fed when it is found to be plentifully co- 
vered with matter. This will generally 
be the cafe about the fourth or fifth day ; 
but as the formation of pus depends up- 
on different circumftances, particularly 
upon the health of the patient, and upon 
the degree of heat in which the parts have 
been kept, fome latitude muft be allowed 

in 



Se£l. IT. Incifed Wounds. 'j'j 

in this matter. A free ufe of poultices, 
after the fecond day, puts it in our power 
to remove the dreflings much fooner than 
we otherwife could do : for they not only 
promote the formation of matter, but 
they foften all the coverings that have 
been ufed, fo as to admit of their being 
eafily taken away. 

When the cure of a wound goes on 
without interruption, the fecond, as well 
as all the fubfequent dreflings, (hould be 
precifely the fame as the firft : for our 
objedl being ftiil the fame, no variation, 
it is evident, can be neceflary. As no- 
thing proves more hurtful to fores than 
expofure to the air, one great objecfl in 
our application of dreffings, is to prevent 
any inconvenience which might arife from 
this. And the fame reafon renders it ne- 
ceffary to change the dreffings as feldom 
as is confident with cleanlincfs ; and to 
be as expeditious as poffible in the renew- 
al of them. In general, however, no harm 
will occur from a daily dreffmg of wounds. 
They fhould not, but in very particular 
F 3 clrcum- 



78; bfftmple Ch. XXXVt. 

circumflances, be drefled more frequent- 
ly J nor can it often be proper to drefs 
them feldomer than this : for when mat- 
ter is allowed to lodge for a longer time, 
the heat in which patients with large 
wounds are ufually kept, is apt to make 
it become putrid and ojSenfive. But as 
I have elfewhere had occafion to fpeak 
fully upon this fubjedl, it is not ndw ne- 
cefTary to enter upon a more particular 
Confideration of it *. I ftiall juft obferve 
farther, with refpecfl to the continuance 
of mild dreffings to wounds, that it ought 
to be regulated by the progrefs of the 
cure. As long as it continues to advance, 
they fliould be perfifted in ; but when the 
fore alTumes appearances in any degree 
inorbid, feme variety in the dreflings 
■will be highly proper ; and the nature of 
4hy change that is to take place muft be 
regulated by the particular fituation of 
the afFeded parts. We muft refer, how- 
<;velr, for a more minute confideration of 

this 

^ Vide Treatife on UlcerSj *^. 



5e6l. II. Incifed Wounds, 79 

this part of our fubjedi to the different 
fedions in the Treatife on Ulcers alluded 
to above. 

We have hitherto been fnppofing that 
none of the fymptoms which take place 
are violent ; in which cafe the cure of 
every wound will, for the moft part, go 
eafily on under the mode of management 
we have mentioned. But in fome cafes 
the cure is not only much interrupted, 
but even much hazard is induced by the 
unufual height to which fome of the 
fymptoms proceed ; and thefe particular- 
ly are, pain, inflammation, and convulfive 
affedlions of different kinds. We J^all 
therefore offer a few obfervations upon 
the means of obviating thefe fymptoms, 
when they proceed to fuch a height as to 
prove any interruption to the cure. 

A wound cannot be inflidled without 
inducing pain : for even the flightefl in- 
jury which can be done to any part of the 
body, muft necelTarily affed fome of the 
fmaller branches of nerves j by which 
F 4 pain, 



8o Offimple ^ Ch. XXXVL 

pain, to a certain degree, will be indu- 
ced. 

It commonly happens, however, that 
any pain which at firft takes place in 
wounds, is not fo fevere as to require any 
particular management : and in general, 
it fubfides entirely upon the removal of 
any extraneous bodies which have been 
introduced J by protedling the injured 
parts with proper coverings ; and by a 
plentiful formation of matter. But in a 
few cafes the pain continues violent after 
every ufual method of removing it has 
been attempted. Opiates in large dofes 
are in fuch circumftances more to be de* 
pended on than any other remedy ; and 
they do not often fail of giving relief. 
But it frequently happens that their effed 
is only temporary, the pain being apt to 
recur after the ftrength of the opiate is 
exhaufted. 

In this event we are to fearch with 
much care for the caufe of the pain. It 
may proceed from fome particles of ex- 
traneous matter which have not been difr 

covered I ' 



Se£t. II. Incifed Wounds. 8i 

covered ; from inflammation of the 
wounded parts ; or from fome portion 
of a nerve or of a tendon being partial- 
ly wounded without being divided ; or 
from irritation over the whole furface of 
the fore. 

We fhould therefore, in the firft place, 
examine the wound with attention, fo as 
to be as certain as poffible that no extra- 
neous matter has found accefs to it : 
for when pain is produced by any fo- 
reign body lodged in a wound, the re- 
moval of it will, for the moft part, pro- 
cure immediate relief ; while no remedy 
that can be advifed will have any efFe<3: 
as long as it is allowed to remain. When 
any thing of this kind is not readily dif- 
covered ; or when the particles of any 
extraneous matter that may be lodged in 
a wound are fo fmall that they cannot be 
removed with the fingers ; we have al- 
ready advifed the injeding of warm wa- 
ter, by which they will often be waflied 
out when every other trial has failed. 
Put when this does not fucceed, it fome- 

times 



82 OffimpU Ch. XXXVI. 

times anfwers to immerfe the wound for 
a confiderable time, perhaps for an hour, 
morning and evening, in warm water, or 
in warm milk ; by which particles of mat- 
ter are fometimes diflblved and carried 
out, which would otherwife have conti- 
nued to excite much uneafinefs. 

If no trial, however, which may be 
made for this purpofe, fhould prove fuc- 
cefsful, we mult look for fome other caufe 
of the pain ; and it will often be found 
to originate from inflammation. When 
the external parts of a wound are infla- 
med, the caufe of the pain is at once ren- 
dered obvious ; for even the flighted de- 
gree of inflammation is very readily dif- 
covered. But it fometimes happens that 
the periofteum, and other deep feated 
parts, are afiedled in this manner with- 
out any external marks of it appearing. 
This, however, is only the cafe for fome 
fliort period after the inflammation has 
commenced : for even when it firfl: at- 
tacks parts that are deeply feated, it com- 
monly fpreads in the courfe of a day or 

two. 



SeCt. II. Incifed Wounds. / 85 

two, fo as to be difcovered 'outwardly; 
and when this does not happen, we may 
in general be diredled to the caufe, by 
the heat of the patient's body ; by the 
flate of his pulfe ; and by the degree of 
thirft, which in every cafe of this kind 
are always increafed. 

When thefe general fymptoms of fever 
run high, it is fometimes necellary to take 
away confiderable quantities of blood by 
one or more general blood-lettings. But 
for the moft part this meafure is not ne- 
ceflary, and our views are obtained with 
more certainty by local blood-letting from 
the edges of the wound by means of 
leeches. In fuch circumftances, indeed, 
no remedy will prove fo fuccefsful as the 
difcharge of blood in this manner. I have 
long been in the daily pradice of ufing 
it in every wound where inflammation 
proceeds to any height ; and I have of- 
ten feen great advantages refult from it. 
In cafes of pain proceeding from this 
caufe, I have known the application of a 
few leeches to the edges of a wound pro- 
cure 



84 Offimple Ch. XXXVI. 

cure immediate relief, even where large 
dofes of opiates, as well as other reme- 
dies, had previoufly been tried in vain. 
And that it is not the quantity of blood, 
but the manner of difcharging it, which 
proves fuccefsful, is evident from this, 
that the pain is often relieved immedi- 
ately on a few drops being taken away 
by means of leeches, which did not yield 
in any degree to tiie lofs of a confider- 
able quantity by venefedion. In ufing 
leeches -for this purpofe, they fliould be 
applied as near as poflible to the edges 
of the wound; nay, when they will fix 
within the wound itfelf, the pradlice 
proves flill more fuccefsful: but unlefs 
the inflammation be very deeply feated, 
this meafure will feldom be necefTary. 
It fometimes happens, however, as we 
have obferved above, that in deep wounds 
no inflammation of any importance ap- 
pears externally, while the periofleum 
is difcovered to be much inflamed and 
very painful. In this fituation nothing 
affords fo much relief as fcarifications 

made 



Seft. II. Incifed Wounds. 85 

made in the inflamed membrane, either 
with the ftioiikler of a lancet or with the 
point of a fcalpel. Nor need wejiefitate 
in pntting them in practice, on the fup- 
pofition of their being apt to produce 
exfoliations of the bone beneath. In- 
flead of this, they tend more certainly 
than any odier remedy to prevent them ; 
for exfoliations feidom happen merely 
from the periofteum being divided ; of 
which we have daily inflances in wounds 
penetrating to this depth, which are rare- 
ly attended with this efFeft ; iinleft the 
bone itfelf be at the fame time confider- 
ably injured. In different cafes I have 
fcarified the periofteum in the manner 
here recommended, which in the mean 
time tended always to remove the inflam- 
mation ; while in no inftance v.'as it pro- 
duaive of any difagreeable confequences. 
On the contrary, there is nothing more 
apt to induce exfoliation than an inflamed 
ftate of the periofteum, when it is allowed 
to proceed to the length of fuppuration : 
and we know no remedy by which this 

is 



S6 Offtmple Ch. XXXVL 

is with fuch certainty prevented as by 
incifions made in the inflamed parts, and 
carried to fuch a depth as to remove the 
tenllon which comimonly takes place. 

After as much blood is difcharged as 
may be judged proper, whether by leech- 
es or fcarifications, no applicacion will 
prove fo ufeful as warm emollient poul- 
tices and fomentations frequently renew- 
ed : for in fuch circumftances nothing 
will afford fuch effe(5lual relief as a plen- 
tiful fuppuration being induced. We 
conftantly obferve, that as long as a 
wound remains dry on the fur face, the 
parts are tenfe, much inflamed, and very 
painful; and that they become lax and 
eafy as foon as they are properly covered 
with purulent matter. 

For the moft part, the means we have 
mentioned will be attended with the de- 
fired efFe(5l ; and efpecially if the opera- 
tor be not too timid in making the fcari- 
fications : for we muft again obferve, that 
they may be done with much more fafe- 
ty and freedom than is commonly ima- 
gined ; 



Sea. II. ' Jncifed Wounds. 87 

gined ; and when membranes in any fi- 
tuation are muph inflamed, nothing with 
which we are acquainted will fo certain- 
ly prevent the acceflion of gangrene as 
deep and free fcarifications. Even this 
remedy, however, will not always fuc- 
ceed : for in fome cafes the inflamma- 
tion, inflead of abating, becomes more 
and more violent, till at lafl: it terminates 
in mortification. Bnt as we have elfe- 
where treated fully of this fubje^, it is 
not at prefent neceflary to enter upon 
it*. 

When wounds are attended with vio- 
lent pain, proceeding from inflammation, 
the caufe is for the mod part very readi- 
ly discovered . But feverer pain fome- 
timesexifts independent of inflammation : 
for although much pain very feldom fails 
to induce an inflamed ftatc of a wound 
at laft, it will often lubfift for a confi- 
derable time before this takes place. In 
fuch cafes, and efpecially where we have 
no caufe to fufpe<ft that it arifes from the 

lodgement 

* Treatife on Ulcers^ &c. Part I. 



88 Of Simple Ch. XXXVI. 

lodgement of extraneous matter, it will 
probably be found to proceed from the 
partial divilion of a nerve or tendon : 
for we know, that in various inftances 
the niofl: excruciating pain has been in- 
duced in this manner. 

In fome cafes, the pain produced in 
this way is efFe<^l:ualIy relieved by putting 
the injured parts into a relaxed flate ; 
but, for the mofl: part, the only remedy 
upon which we can depend is a complete 
divifion of the wounded nerve or tendon : 
and as this is a means of cure which may 
at all times be pradlifed without ri(k, it 
fhould never be delayed when the pain 
is found to proceed from this caufe ; and 
efpecially when, from its violence, there 
is reafon to fufpecl that it may induce 
convulfions or any other alarming fymp- 
toms. As a free ufe of the fcalpel, how- 
ever, is neceffary, patients in general do 
not eafily fubmit to this divifion ; nor do 
we commonly find that praditioners are 
apt to recommend it. But I can fay from 
different inftances of its beneficial effetfls, 

that 



Se£t. 11. Incifed Wounds. 89 

that we ought more frequently to prac- 
tif'e it: for it feldom fails to' afford im- 
mediate relief, even in the fevereft de- 
grees of piin ; and I never knew any bad 
effect refult from it. It ought always, 
however, to be advifed as foon as any 
other means that may be employed have 
failed : for when violent pain has fub- 
fifted To long as to induce any material 
affedlion of the convulfive kind, even this 
remedy will not readily reiuove it. On 
the parts being freely divided, they 
Ihould be placed in a relaxed pofture ; 
and an emollient poultice being laid over 
them, if the praflice proves fuccefsful, 
the patient will foon find himfelf relieved 
from his diftrefs, and the wound mav af- 
terwards be treated in the ufual way. Buc 
when it fails, as it will be apt to do, when 
from timidity, or any other caufe, it has 
been long delayed, there will be much 
caufe to fufpedl that the patient will at 
laft die convulfed, notwithftanding the 
ufe of opiates, and every other remedy 
that may be employed. 

Vol. V. G In 



go Offtmpk Ch. XXXVI. 

In fome cafes again, the pain which oc- 
curs in wounds, inftead of being deep 
feated, which it always is when it pro- 
ceeds from an affedlion of any particular 
nerve or tendon, is found to originate 
from a peculiar degree of irritability of 
the nerves on the furface of the mjured 
parts. The pain, in fuch inftances, is 
not very fevere ; but it often proceeds to 
fuch a length as to excite much uneafi- 
nefs, by which the patient is apt to be 
deprived of reft, and the matter difchar- 
ged from the fore to be rendered fharp 
and acrid. 

For the removal of this kind of pain, 
emollient poultices, and other warm ap- 
plications, are commonly employed; but 
feldom with any advantage. Indeed they 
often feem to increafe the irritabiUty. 
Large dofes of opium afford the moft 
certain relief j and a folution of opium 
in water, or a weak folution of faccharum 
faturni, are the beft external remedies. 
When of a proper ftrength, they com- 
monly prove fuccefsful. 

While treating of the caufe and removal 

of 



Se£t. II. Incifed Wounds. $t 

of pain in wounds, it was neceflary to 
mention inflammation, with the means 
bed adapted for the cure of it. We have 
now to attend to the nature and treat- 
ment of fome convulfive affections which 
injuries of this kind fometimes induce. 

Subfultus tendinum, and other fpafmo- 
dic affedlions of a flight nature, are fre- 
quent confequences of wounds: They are 
more particularly apt to occur from the 
amputation of limbs, when they often, 
prove the caufe of mucb uneafinefs and 
pain; for the ftarting which they are 
apt to excite in the affeded limb, produ- 
ces a violence of aftion which mufcular 
parts newly divided are not well fitted to 
fupport. And when they are fevere, 
and return frequently, they prevent the 
dreflings from being kept properly ap- 
plied, at the fame time that they are often 
the caule of hemorrhagies from arteries 
which have even been tied with ligatures. 
We ought, therefore, in every inftance, 
to treat them with attention. Indeed 
the rifk of their producing hemorrhagies 
G 2 is 



92 Offtmpk Ch. XXXVL 

is (o confiderable, and the fenfations 
which they communicate to the patient 
are fo difagreeable, that a prudent prac- 
titioner will at all times confider them 
to be of importance. 

As thefe convulfive twitchings are evi- 
dently the confequences of pain and ir- 
ritation produced by the wound, it is 
obvious that thofe means are molt likely 
to prove eft'eiflual in removing them 
which are moft powerful in procuring 
eafe. Hence much advantage is derived 
from placing the patient's body, aqd efpe- 
cialiy . the affeded limb, in the eafieft 
pofture : indeed more benefit is derived 
from it than we are often aware of. I 
have known fevere- degrees of this affec- 
tion relieved almoft immediately, by 
changing the pofture of a ftump. But 
when this does not prove fuccefsful, opi- 
ates will feldom fail. 

It is worthy of obfervation, in ufing 
opium for this purpofe, that it anfwers 
better to give it in fmall dofes frequent- 
ly repeated, than to give large dofes at 

once. 



Sed. II. Incifed Wounds. 93 

once. The latter often produce ficknefs, 
and even vomiting ; and after their ef- 
fe^s are over, the ipafms are ^pt to be- 
come more fevere tlian they were at firfl: ; 
which we feldom find to happen when the 
remedy is nfed in fmaller dofes, and re- 
peated at proper intervals. 

There are other convullive affediions, 
however, ftill more alarming, which 
even in this country fometimes occur 
from wounds, but which happen much 
more frequently in warm cHmates ; tlie 
locked-jaw, and tetanus. Thefe afFedlions 
proceed in many inftances, indeed, from 
other caufes ; the nature of which we 
cannot difcover : but when they are not 
obvioufly induced by deep or extenfive 
wounds, they may often be traced, by a 
more minute invefligation, to ibme flight 
injury done to the furface of the body. 
Even the flighteft fcratch, which does not 
penetrate to a greater depth than the 
ikin, has been known to induce them. 

As we know that fevere degrees of 

pain are often produ<ftive of involuntary 

contradlions of fuch mufcles as have been 

G 3 injured 



94 Offtmple Ch. XXXVL 

Injured, we would naturally expert that 
extenfive wounds would be frequently 
attended with this efFedl. But we do not 
fo readily Tee how the moll; violent affec- 
tions of this kind fhould occur from fuch 
wounds as are fo flight as fcarcely to be 
-noticed, and which never of themfelves 
produced much uneafinefs. 

Nor do injuries of greater importance 
induce thefe fymptoms fo readily while 
they are recent and painful: for they fel- 
dom occur in large wounds till the cure 
is far advanced ; and in fome inffances, 
particularly after the amputation of 
limbs, they are never more apt to appear 
than when the cicatrix is nearly comple- 
ted. At lead this has been the cafe in 
almoft every inllancc of this kind which 
I have met with in this country ; and we 
are told from very certain authority, that 
|:hc fame obfervation has been made in 
warm climates ^. 

The 

* Vide Obfervatlons on the Difeafes incident to Seamen, 
|>y Gilbert Blane, M. D. &c. 



Seel. II. Jncifed Wounds. 95 

The caufe of this may be difficult to 
explain ; but our knowledge of the fa<ft 
leads to fome advantage in pradlice. We 
have hitherto been made to fuppofe, that 
the lockcd-jaw, and other convulfive 
fymptoms which fometimes fucceed to 
wounds, are moll: apt to occur from the 
violence of pain induced at, or ibon af- 
ter the time of wounds being inflid:ed ; 
and therefore prac'litioners have guard- 
ed with mofl alTiduity againft them while 
the pain has continued fevere. But when 
it is known that they feldom or never 
occur at this period, and that they fre* 
quently appear in more advanced ftages 
of wounds, thofe means of prevention 
which are found to prove moll eifedual, 
will more readily adl with advantage if 
applied at this time. 

Practitioners, therefore, in warm cli- 
mates, (liould be particularly attentive in 
the advanced ftages of wounds; and the 
moft efFe<ftual remedy which can be ap- 
plied on the firft appearance of a locked- 
jaw, is immerfing the patient, fo as to 
G 4 cover 



96 0/fim/e ■ Ch. XXXVI, 

cover the whole body in a v/arm bath. 
T^ heat of the baih (hould be regulated 
by rhe feelinos of the patient ; and he 
fhould continue in it as lonc^ as he is able 
to bear it. Water is commonly ufed for 
this purpofe ; bvit where milk can be pro- 
cured, it fhould be preferred: for as a 
warm bath proves, in cafes of this kind, 
chiefly ufeful by its relaxing powers, we 
have reafon to fuppole that the oily par- 
ticles contained in milk render it parti- 
cularly proper; and the idea appears to 
be well founded by the beneficial effedls 
which in different inftances have refult- 
ed from the ufe of it. 

It may often happen, however, that 
milk cannot be procured in quantities 
fufficient for this purpofe. Jn fuch iitua- 
tions, fat broths, or water combined with 
oil in any other manner, may be ufed 
inftead of it. When one application of 
a bath proves fuccefsfnl, the ufe of it 
need not be continued ; but for the moft 
part feveral repetitions of it are neceffary, 
Mor are we to imagine that warmb atb- 

ins 



Seft. II. Inctfed Wounds. 97 

in"" Is a certain remedy. It has frequent- 
ly indeed proved highly ufeful, and n;ja- 
ny cures have been accomplitlied by it; 
but we muft llkewife confeCs that it has 
often failed, and that patients are daily 
carried off in warm climates by thelock- 
ed-jaw, and other convulfive fymptoms, 
notwithftanding the moft ample applica- 
tion of the warm bath, and of every other 
remedy that has hitherto been employed. 

The failure of warm bathing has in- 
duced fome practitioners to make trial of 
the cold-bath ; and in fome convulfive 
affedions it has certainly proved ufeful ; 
particularly in cafes of univerfal tetanus: 
but as yet it has not been fo frequently 
employed as to enable us to judge with 
precifion, whether it will often prove 
ufeful or not in the locked-jaw, which 
we are to confider as the mod obftinate 
as well as the molt dangerous fymptom 
of this kind. 

At the fame time that we perfift in 
the uie of warm bathing, other remedies 
ought not to be negledted ; and of thefe 

opium 



98 Offiwple Ch. XXXVI. 

opium Is the moll certain. It proves 
iifefful both as an external application 
and as an internal medecine. By rub- 
bing the contracted mulcles with lauda- 
num, or by keeping them covered with 
an extract of opium, or with opium 
merely foftened with fpirits or water, the 
fpafm has in feme inltances been lelFen- 
cd : but the moft efFe<51:ual relief obtained 
from this remedy is by giving it inwardly; 
not in large quantities as we have remark- 
ed above, but in fmall dofes, frequently 
repeated. The dofes (hould be fuch, how- 
ever, as may effedually allay the pain 
and uneafinefs produced by the difeafe ; 
but more than this is unneceflary : and, 
when exhibited in large quantities, ^t 
feems to do mifchief, by inducing that 
very ftate of the fyftem it was meant to 
prevent, namely a great degree of irrita- 
bility : for as foon as the operation of a 
large dofe of opium is over, we common- 
ly find, in all fpafmodic affedions, that 
the difeafe returns with double violence. 
But this may be eafily prevented, by gi- 
ving 



Seft. II. Incifed Wounds. " 99 

ving fuch dofes as the patient can eafily 
bear, and repeating them at fliort intter- 
vals, in fuch a manner that the efFeds of 
orvemay, not be over before another is 
given. jEther and mufk have fbme- 
times been conjoined with opium ; but 
no advantage of importance has been 
derived from them. 

We have mentioned opium as an ex- 
ternal application ; but the remedies of 
this kind from which we would expeft 
moft advantage are emollients, freely 
applied over all the contracfted parts. 
The nature of the difeafe feems ftrongly 
to point them out; and experience has, in 
fome inflances, (hown that they may be 
uied with advantage. Emollients of every 
kind may be ufed for this purpofe ; but 
animal fats of the fofter kinds feem to be 
preferable : for they certainly prove more 
powerfully relaxing in all cafes of con- 
tracfted mufcles than any of the vegetable 
oils ; at leaft, in the courfe of my expe- 
rience, they have uniformly proved to 
be fo. By boiling recent bones in water. 



loo OffimpU Ch. XXX VL 

a very pure oil of this kind is obtained ; 
and the fat of all kinds of fowls anfwers 
well. 

Mercurials have been frequently given 
in difeafes of this kind : but if mercury 
has ever proved ufeful, it has been in fuch 
cafes only where it was rubbed upon the 
contracted parts in the form of an oint- 
ment, and where it would probably aft 
with advantage as an emollient. 

When a locked-jaw occurs from a 
wound in any ol the extremities, if the 
difeafe does not yield to the remedies we 
have mentioned, it has been propofed to 
amputate the member ; and in various 
cafes this hath been pradi fed. I am forry, 
however, to obferve, that we have fcarce- 
ly an inflance of its proving eifedual : 
for in this difeafe, as in almofteveryfpaf- 
modic affedlion, the effeft is apt to re- 
main after the caufe is removed. We 
have therefore no encouragement, from 
paft experience, to put this remedy In 
practice. Inflead of proving ufeful, the 
difeafe has, in different inflances, been 

evi- 



Sed. II. Incifed Wounds, loi 

evidently rendered worfe by it. The re- 
medies therefore which we have to truft 
to, are thofe we have mentioned above, 
namely, the warm bath, opiates, and a 
very free application of emollients. 

While we are depending^ on thefe for 
efleding a cure, the patient's ftrength 
fhould be Aipported by mild nourifhment 
given by the mouth, when this can be 
done; and by glyfters of ftrong broths, 
when the jaws are fo firmly contraded as 
to prevent food from being received by 
the mouth : And we may, by removing a 
tooth or two, even in cafes of this kind, 
convey food to the ftomach ; fo that 
wherever the fymptoms of locked-jaw are 
obferved to be approaching, one or two 
of the teeth fhould be taken out, as they 
eannot be removed but with nluch more 
difficulty after the jaws are firmly clinch- 
ed. 

Having thus conlidered the various cir- 
cumftances relating to wounds in their 
mod ufual form, with the means of cure 
adapted tio each of them, we fhall now 

proceed 



/ 

I02 Of Pundured Wounds. Ch. XXXVI. 

proceed to mention more particularly 
fome varieties in thofe affections which 
point out a different mode of treatment ; 
and thefe are, pundtures, laceration, and 
contufion, ' 

SECTION III. 
OfPundured Wounds. 

A Wound is faid to be pundlured 
when it is made with a fmall point- 
ed inftrument ; and when the external 
aperture, inftead of being wide and ex- 
tenfive in proportion to the depth, is fmall 
and contradled. A wound made by a 
tbruft of a fmall fword is of this kind. 

Wounds of this kind prove, in general, 
more hazardous than incifed wounds of a 
much greater extent ; from deep feated 
nerves and other parts of importance be- 
ing more apt to be partially hurt ; from 
extraneous bodies being carried to a depth 
from whence they cannot be eafily remo- 
ved ; 



Sea. III. OfPundured Wounds, 103 

ved; from the dlfcharge which they afford 
being more apt to lodge ; and from the 
fides of the punctured parts being in ma- 
ny inftances made to adhere with diffi- 
culty. Thefe are points of the utmofl. 
moment, not only from their being often 
produiflive of much diftrefs to patients, 
but from the cmbarrafTment which they 
give to practitioners, who are more apt 
to fail in their treatment of this variety 
of wound than of any other which falls 
within their management. 

It is obvious, that all the rifk which 
occurs in thefe wounds proceeds from 
their being fo contracted, that free accefs 
cannot be got to their full depth : And 
it is equally evident that this can be ob- 
viated only by laying them freely open. 
Indeed, this is the idea which, in the 
treatment of punClured wounds, we (liould 
always keep in view, that of converting 
them as far as polTible into incifed wounds 
with wide extenfivc openings. This, 
however, is a queftion about which prac- 
titioners are not agreed : Some advife the. 

openings 



I04 Of Punaured Wounds. Ch. XXXVL 

openings of pundlured wounds to be en- 
larged either with tents or with the fcal- 
pel ; while others alledge that this is fel- 
dom requifite : And they have alfo dif- 
fered with refpedl to the time at which 
any dilatation of this kind Ihould be 
made ; for while feme advife it to be de- 
layed for a few days only, others do not 
attempt it till every other means have 
failed. 

In the treatment of pun<5lured wounds 
our views ought to be the fame as in cafes 
of finus. Indeed, a wound of this kind 
is exadlly a finus in a recent ftate ; and 
by confidering it as fuch, the means of 
cure that will mod likely prove fuccefs- 
ful are at once pointed out. In every 
finus, our intention is to procure a re- 
union of the parts which have been di- 
vided ; but w^e know from experience 
that this cannot be effedled till a certain 
degree of inflammation is induced upon 
them. For this purpofe, the intiodudlion 
of a cord or fetovi along the courfe of a 
finus has frequently proved fuccefsful ; 

and 



Sea. III. Of Pundured Wounds. 105 

and fome have, with the fame views, em- 
ployed irritating injecftlons. When by 
thefe means the internal fnrface of the 
finus is fufficiently inflamed, the cure is 
to be completed, by compreffion applied 
in fiich a manner as to keep the parts in- 
tended to be united in clofe contadl, till 
a fufficient degree of adhefion is produ- 
ced. Now, in the application' of this 
treatment to pundured wounds, it is ob- 
vious, that the previous fteps which we 
have mentioned for exciting inflamma- 
tion, would feldom if ever be neceflary ; 
for one certain effecft of every wound is 
to induce inflammation over all the parts 
which have been injured : So that a priori 
we fliould be led to conclude, that com- 
preffion alone would in all fuch cafes 
prove fucccfsful: for we know that it 
feldom fails in other cafes of finus where 
a due degree of inflammation is indu- 
ced. But we are deterred, in punc- 
tured wounds, from the immediate ufe 
of this remedy ; at leafl: where they pe- 
netrate to any confiderable depth, from 
Vol. V. H pur 



io6 Of Punaured Wounds. Ch. XXXVt 

our uncertainty with refpedl to extra- 
neous bodies being lodged in them or not, 
and from the inflammation in wounds of 
this kind being apt to run too high. In 
iuperficial wounds, indeed, where we are 
certain of being able to extra(!il any ex- 
traneous matter, and where the inflam- 
siiation is for the moft part moderate, 
compreflion may be employed immedi- 
ately; and when properly applied, it will 
not often fail. But for the reafons juft 
mentioned, it can feldom be employed 
with fafety in wounds of much import- 
ance. 

The pradlice I have long adopted in 
wounds of this kind is this: When they 
fun in fuch a diredlion as to prevent a 
feton from being carried along their 
whole cbnrfe, I lay them open immedi- 
ately from one extremity to the other, or 
as far as it can be done with fafety, ei- 
ther with a probe-pointed biftoury, or 
with a fcalpel and diredlor : and this be- 
ing done, the parts are drefTed in the 
manner we have advifed above, in cafes 

of 



Sed. III. Of Pun^liired Wounds. 107 

of fimple incifed wounds. But when it 
appears that a feton can with propriety be 
ufed, emollient poultices are firfl: applied 
and continued till a free fuppuration is 
induced, and till there is no longer any 
caufe to fear that the fymptoms of in- 
flammation are to proceed too far. A 
cord is then introduced nearly equal to 
the fize of the opening ; and being al- 
lowed to remain till there is reafon to 
imagine that any extraneous matter lod- 
ged in the wound is difcharged, it is then 
gradually leflened, by taking away a 
thread or two every three or four days ; 
and when reduced to a third or fourth 
part of its original thicknefs, it is taken 
out entirely ; when the remainder of the 
cure is for the moft part eafily effedled, by 
the application of moderate preflfure along 
the courfe of the wound. 

When a pundlured wound is laid open 
at both ends, a cord may be eafily intro- 
duced by means of a blunt probe, with 
an eye at the end of it. But when the 
inftrument has not pafTed through the 
H 2 integuments 



io8 Of PunBured Wounds, Ch. XXXVI. 

integuments on the oppofite fide to which 
it entered, a counter opening mud be 
made, either by cutting with a fcalpel 
on the round end of a blunt probe, or by 
pafTing a lancet-pointed needle, covered 
with a canula, along the finus, and pufliing 
it out at the oppofite fide with the feton 
attached to it. 

In either of thefe ways the cure of 
fucli wounds may often be accomplifh- 
ed. But wherever the pra6lice is admif- 
lible, I am clearly of opinion, that lay- 
ing them open immediately after the ac- 
cident is preferable to the other : for 
by means of it all extraneous bodies are 
at once brought into view ; hemorrha- 
gies ' are eafily reftrained ; and all that 
pain and trouble which fometimes occur 
from a partial divifion of nerves or ten- 
dons are diredly obviated. Nor is the 
inflammation, which often fucceeds to 
pundlured wounds, apt to run fo high as 
it uiually does when any other mode of 
treatment is adopted : So that much 
diftrefs would be prevented, and much 

time 



Seft. III. Of PunBured Wounds. 109 

time faved, if this method of cure was 
more generally pradifed. To thofe not 
much accuftomed to this kind of bufi- 
nefs, the enlarging of a fmall punfture, 
i^o as to form an extenfive wound, ap- 
pears to be unnecefTary and cruel : but 
whoever has feen much of this branch 
of pracflice will know, that the greateft 
diftrefs often arifes from the fmallefl 
pundtures ; that furgeons are often baf- 
fled and much difappointed in their treat- 
ment of them ; and he will foon lind, 
that nothing fo efFeclually obviates this 
as the pradice we have mentioned, that 
of laying the punctures freely open as 
foon as poffible after they are Inflicted. 
Indeed, the fooner It is done, the better. 
No advantage can accrue from delaying 
it ; and a patient always fubmlts to it 
mod readily at firll, while, at the fame 
time It Is productive of lefs pain than it 
mufl: necefTarlly give when the parts 
are fvvelled and Inflamed, which they 
commonly are in the courfe of a few 
days from the time of fuch Injuries 
H 3 being 



I ID Of Pmaured Wounds. Ch. XXXVI. 

being infli6led. In every wound there- 
fore of tb^s kind, particularly in thofc 
vvhich are often received in duels with 
fmail fwords, and in battles with the 
points of bayonets, the enlargement 
ihould take place even before the parties 
are carried from the field ; by which ma- 
ny inconveniences which naturally at- 
tend thefe injuries would be prevented. 

There are fome cafes, however, in 
which this pradlice cannot with proprie- 
ty be followed ; in pundtures which run 
deep among the large mufcles ; and efpe- 
cially in I'uch as are contiguous to any 
of the large blood-vefTels and nerves. As 
rnore danger would accrue from wound- 
ing thefe than could probably be com- 
penfated by any advantage gained by di- 
lating the wounds, it is better in fuch 
circum fiances to reft fatisfied with lay- 
ing the parts open as far as it can be done 
with fafety ; to truft to the fuppuration 
which will enfue for bringing off any ex- 
traneous matter that may be lodged in 
the wound J and to a proper application 

of 



Sea. III. Of Punaured Wounds. ni 

of prefTure for completing the cure. Or 
the pradice we have mentioned above, of 
introdacing a fcton, may be attempted ; 
for a cord may be pafleJ with fafety 
where it might be very improper and 
even dangerous to make a deep incifion. 
But it is proper to obferve, that there are 
fome cafes in which even a feton cannot 
be introduced: for a puncture fometimes 
runs in fuch a diredion, as not to ad- 
mit of a counter-opening. We muft here 
truft to a proper application of prclTure, 
not merely for preventing any Jodgemenc 
of matter, but for effecting a cure by 
producing an adhefion of the divided 
parts ; and when this fails, injedions of 
a moderate degree of aftringency may be 
ufed with advantage: but as remedies 
of this kind tend to counterad the very 
intention for which fetons are employed, 
chey ttiould never be advifed till it ap- 
pears that the latter will not fucceed. 
Sctons, as we have already obferved, 
prove ufeful, by exciting inflammation 
^long the courfe of a finus. Now, one 
H ij. ufu^ 



ii2 Of Punaured Wounds. Ch. XXXVI, 

ufual efFeft of aftringent applications is, 
to dlminifli or even to remove inflam- 
mation. They (hould never therefore 
be employed till all the ordinary means 
of cure have failed, when they may be 
ufed with a view to chrck the flow of 
matter when it is difcharged in too great 
quantities, and in order to induce fome 
degree of callofity over the fides of the 
fores. 

We think it right in this place to remark, 
that pradlitioners have differed much in 
their opinions with refpedl to the ufe of 
aftringent inje(^tionsin wounds: for while 
fome are in the daily habit of employing 
them, others havefaid that they are always 
pernicious, and ought never to be ufed. 
In the early ftages of wounds they can 
never be neceflliry ; and as they may do 
harm by wafliing away the matter too 
freely, they fliould never be ufed as long 
as a cure is expelled, either by the for- 
mation of new granulations, or by adhe- 
iion : but whenever we have reafon tp 
conclude that this cannot probably hap- 
pen. 



Sea. III. Of PmElured Wounds, 113 

pen, we may with propriety recommend 
them. Various forms of chem are men- 
tioned by authors ; but none of them are 
fo harmlefs, and at the fame time anfwer 
with fuch certainty, as weak folutions of 
faccharum faturni. Lime-water is ufed 
with the fame views; and water ftrongly 
impregnated with alum, or mixed with 
an equal quantity of claret or port-wine, 
is often employed with fuccefs. 

In the treatment of pundlured wounds 
where fetons cannot be employed, it is 
fometimes difficult to prevent the exter- 
nal aperture from clofing long before 
any tendency to heal appears in the bot- 
tom of the fore; and if it be not prevent- 
ed, much mifchief is apt to enfue by mat- 
ter collecting beneath, and burfting out 
from time to time. With a view to pre- 
vent this difagreeable occurrence, tents 
are employed of prepared fponge, gen- 
tian root, and other articles, which, by 
fwelling with the moifture of the fores, 
ferve very effedually to keep them open. 

But 



114 Of Punaured Wounds. Ch. XXXVL 

But while they anfwer this purpofe, they 
are very apt to do mifchief. When the 
opening of a fore is plugged up with a 
tent, the matter which forms can never 
be difcharged but at the renewal of the 
dreflings ; by which means it will necef- 
larily colledt in fuch quantities as to give 
rife to abforption, as well as to the for- 
•niation of finufes, by the matter fpread- 
ing between the layers of the contiguous 
mufcles. Tents, therefore, which are of 
folid materials, ought never to be of fuch 
a magnitude as to fill the openings of fores. 
They will not readily do harm when they 
are of fuch a diameter as to admit of a dif- 
charge of matter while they are inferted. 
But when they are employed of fuch 
fizes as to fill the openings entirely, they 
ought always to be hollow ; by which the 
apertures into the fores will be prevent- 
ed from contracting, while the matter 
will be difcharged as quickly as it is 
formed. For this purpofe practitioners 
fliould be provided with tubes of diffe- 

renc 



Seft. III. Of Pundured Wounds. 115 

rent forms and (Izes, lb as to be able to 
fuit any aperture they meet with. Sil- 
ver tubes are commonly employed ; but 
thofc of lead anfwer better. Being foft- 
er than the others, they do not create 
fo much uneafinefs, and they are more 
readily formed into any particular (hape, 
fo as to anfwer for finufes of a ftraight 
or crooked diredlion. 

We muft obferve, however, that tents 
and tubes of every kind Qiouldbe u fed with 
caution ; and it is more particularly necef- 
fary that this fhould be held forth to be- 
ginners, for there is no point in pradlice 
in which they are more apt to err. As 
they are early made fenfible of the danger 
which enfues from matter being allowed 
to colledl in fores, they very univerfally 
fly to the alTiftance of tents wherever a 
pundlure or a finus is difcovered. But 
it is right they fliould know that tents are 
feldom neceflary : for when once a vent 
is given to matter, the opening will in 
general be preferved merely by the con- 
tinuance 



ii6 Of Lacerated Ch. XXXVL 

tinuance of the difcharge. In a few in- 
ftances, indeed, it is otherwife ; and in 
all fuch cafes the leaden tubes fliould be 
preferred. 

We come now to fpeak of thofe 
wounds which are attended with lace- 
ration and concufion ; and as both of 
thefe circumftances require nearly the 
fame method of treatment, it will not 
be necefTary to fpeak of them in feparate 
fedions. 



SECTION IV. 

Of Lacerated and Contufed Wounds. 

yV Wou ND is faid to be lacerated, when 
the pajrts, inflead of being divided 
•with a (harp-cutting inflrument, are for- 
cibly tore afunder ; and when, inftead of 
a fmooth equal furface, the edges are 
ragged and unequal : And we conclude, 
that contufion takes place when a wound 

has 



Sed. IV. and Contufed Wounds. iij 

has been made with a blunt ©r obtufe 

body. 

Contufed and lacerated wounds differ 

in many points from fimple incifed 
wounds ; t>ut in nothing more than in 
this, that while they are commonly more 
hazardous, they feldom at firft exhibit 
fuch alarming appearances. Thus a 
fimple cut, wiiich commonly heals with 
eafe, is often attended with a much 
greater retradion of the divided parts, 
and with more profufe hemorrhagy, than 
a contufed or lacerated wound. Indeed 
it is a frequent effeft of contufion and 
laceration to prevent the effuflon of 
blood, by which inattentive obfervers, 
in forming opinions of injuries of this 
kind, are very apt to be deceived : for 
as hemorrhagy is the mofl alarming 
fymptom with which wounds are attend- 
ed, when it does not occur to any great 
height, they are apt to conclude that 
nothing bad can happen. Praaitioners 
af experience, however, will not be de- 
ceived by this: for ic has long been 

known. 



1 1 8 Of Lacerated Ch. XXX VI. 

known, that injuries of this kind prove 
always more dangerous than any other 
kind of wound ; and the more violent 
the contufion or laceration has been, the 
lefs blood is always poured out, infomuch 
that there are inftances even of limbs be- 
ing tore off without any hemorrhagy en- 
fuing. 

The pain of lacerated and contufed 
wounds generally varies according to the 
violence of the injury. Thus, in leffer 
contufions, the pain is often fevere, while 
it is apt to be inconfiderable where the 
nerves of any part have been completely 
deftroyed. 

The immediate effedl, both of lacera- 
tion and contufion, is fwelling or tume- 
fadlion, which always takes place in a 
greater or leffer degree in the retradled 
edges of the wound. This feeras to be 
the confequence of effufion into the fur- 
rounding cellular fubflance. When the 
violence has not been fevere, this effufion 
commonly terminates in fuppuration ; 
the contufed parts feparate from thofc 

beneath 



Seft. IV. and Contufed Wounds. 119 

beneath in the form of floughs ; and a 
cure of the remaining fore is obtained 
by the means we pointed out when fpeak- 
ing of fimple incifeiil wounds. But when 
the parts are fo much injured as to have 
their texture much deflroyed, and efpe- 
cially when any of the larger arteries 
have been obUtented, there will always 
be caufe to fufpecl that mortification will 
occur. In found conftitutions, and where 
the wound is not extenfive, even this will 
not often prove fatal : for in fuch cir- 
cumftances the mortified parts common- 
ly fall foon ofi^, and a cure is afterwards 
efFeded in the ufual manner. But in 
wounds attended with contufion or lace- 
ration to any confiderable extent, if the 
habit of body be not perfedlly good, the 
gangrene which cnfues is always to be 
confidered as hazardous : for the difeafe 
does not neceflarily ftop with the parts 
which have been injured; but is apt to 
proceed to ihofe which were not imme- 
diately hurt by the accident. 

And again, even where mortification 

does 



I20 Of Lacerated Ch. XXX VL 

does not fucceed im mediately, when parts 
have been either much lacerated or con- 
tufed, fuch a violent degree of inflam- 
mation is apt to occur as often termi- 
nates in mortification, notvvichrtanding 
all our endeavours to prevent it ; and 
in whatever way the difeafe be induced, 
it is always attended with much danger : 
for befides the rifk of parts being de- 
ftroyed by it, which are immediately 
neceflary for life, the abforption ofpu- 
, trid matter from a gangrenous furface 
proves' often fuddenly fatal, even when 
the fize of the fore is fo inconfiderable 
as to give no caufe to fufpeft danger. 

It is therefore obvious in the treat- 
ment of contufed and lacerated wounds, 
that our principal objedl is to guard a- 
gainfl: the accellion of gangrene. But it 
is likewife clear, that this is not always 
to be done by the fame fort of means : 
for we may readily fuppofe, that much 
advantage may be derived from blood- 
letting, and other evacuations, where the 
injured parts are highly inflamed, while 

no 



Sect. IV. and Contufed Wounds. i 2 i 

tio benefit would probably refult from 
them in any other fituation. This, how- 
ever, is a point of importance, and merits 
particular attention. 

In lacerated or contufed wounds, where 
the parts are much injured, it is the com- 
mon practice to give large quantities of 
bark almoft immediately, and to apply 
warm dreflings and other antifeptics with 
a view to prevent gangrene. It is evi- 
dent, however, that the indifcriminate 
adoption of this pradlice mud frequently 
do mifchief : for however beneficial it 
may be in particular cafes, where gan- 
grene has already taken place, it is cer- 
tain that it will rather do harm where 
fymptoms of inflammation flill continue 
violent j and unlefs mortification adlually 
exifts, it is not clear that in a«y inftance 
it will prove ferviceable ; for although 
we have various proofs of the efficacy of 
bark in putting a flop to the progrefs of 
gangrene, I have never in any cafe been 
fenfible of any advantage being derived 

Vol. V. I from 



122 Of Lacerated Ch. XXXVL 

from it when ufed as a prevenilve of 
it. 

Gangrene may arile in thefe wounds 
from two caufes : From the lloppage 
of the ch-culatlon by the total de- 
(Irudion of the large blood-veifels of 
a part ; and from violent inflamma. 
tion. 

Gangrene proceeding from inflamma- 
tion is mofl: to "be dreaded herb ; for that 
which arifes from the deflrLi(ftion of blood- 
vefTels is by no means fo frequent. The 
inflammation therefore which takes place 
in wounds of this kind, will always de- 
mand our attention in the firfl: place. 

As the hemorrhagy, fubfequent to con- 
tufion or laceration, is feldom alarming, 
and as bjood dilcharged from any of the 
vefTcls that liave been injured tends more 
effedually than any other remedy to pre- 
vent inflammatoin ; fuch quantities fliould 
be taken away in this manner as the na- 
ture of the injury may indicate, and as the 
ilrength of the patient may admit. Af- 
ter 



Sea. IV. and Contufed Wounds. 123 

ter this, if the divided arteries continue 
to throw out blood, they muft be fecu- 
red by ligature : for till the difcharge 
of blood be (topped, the patient will not 
conficler himfelf as fafe ; nor can the 
wound be examined with accuracy. The 
parts are now to be cleared of all extra- 
neous bodies, as far as this can be done 
with propriety, and are to be placed as 
much as poffible in their natural fitua- 
tion ; but no kind of future fhould be 
employed for their retention. If the 
violence which has been done to them 
has been confiderable, and efpecially if 
the patient complains of much pain, it 
will be flill neceffary to take away blood 
in proportion to the ftrength of the pa- 
tient : and as local blood-letting proves 
in fuch cafes always highly ferviceable, 
the beft method of difcharging it is by 
means of leeches, applied as near as pof^ 
fible to the edges of the fore. Indeed no 
remedy I have ever employed proves fo 
certainly ufeful as the difchairge of blood 
in this manner ; for it not only tends to 
I 2 prevent 



124 Of Lacerated Ch. XXXVL 

prevent the inflammatory fymptoms from 
running high, but it very commonly ren- 
ders the pain moderate, even when it has 
previoufly been feveie. It ought never 
therefore to be omitted ; but the pradli- 
tioner fhould take care that it be propor- 
tioned as nearly as poffible to the vio- 
lence or urgency of the fymptoms : for 
the difcharge of a fmall quantity of blood 
will in feme cafes of contufion or lace- 
ration prove fully fufhcient ; while in 
others, it is neceflary to repeat the ope- 
ration once and again. 

As foon as a fufBcient quantity of 
blood is difcharged, the parts affedled, 
after being dreffed with pledgits of any 
emollient ointment, fliould be complete- 
ly covered with a warm emollient poul- 
tice ; and this, together with warm fo- 
mentations, fliould be renewed three or 
four times a-day, fo as to promote, 
■with as much certainty as poflible, the 
formation of pus. To induce fuppu- 
ration in wounds of this kind, is in- 
deed an objedl of the firft importance: 

it 



Seft. IV. and Contufed Wounds, 125 

it generally relieves all the fymp- 
toms ; and till fiich time as it takes 
place, we have often reafon to dread the 
event. 

We commonly find, when fores of this 
defcriptionbecome covered with good pus, 
that the pain and tenlion abate; and fuch 
of the parts as have been much lacerated 
and contufed, and which hitherto have 
been floughy or perhaps black with mor- 
tification, begin now to feparate from 
thofe beneath : and this being accom- 
pliQied, they may in general be cured in 
the fame manner with wounds of any 
other kind. Nay, when brought to this 
healing ftate, we may even attempt with 
fafety to ex.pedite the cure by drawing 
the edges of the retraded fkin into con- 
tact, either by means of the uniting 
bandage or with adhefive plafters ; for al- 
though this would be improper in the 
commencement of fuch wounds, while 
there is any rifk of the tenfion and in- 
flammation proceeding too far, it may 
with much propriety be advifed when 
I 3 there 



S26 Of Lacerated Ch. XXXVI. 

there is no longer any reafon to be afraid 
of thefe fymptoms. 

When pradVicioners are immediately 
called, fo as to employ the means we 
have mentioned in due time, they will 
not often fail in ordinary cafes : but it 
frequently happens, whether from the 
violence of the injury, the tendency in 
Ibme conflitutions not only to inflamma- 
tion but to gangrene, or from the proper 
remedies not being timeoufly applied, 
that all the fymptoms become daily worfe, 
and, notvvithdanding repeated blood- 
lettings both general and local, all thofe 
parts which were at firft inflamed become 
perfectly black and mortified. We arc 
not now to trufl: to evacuations: on the 
contrary, whatever tends to debilitate 
fliould be avoided ; and we know from 
experience, that, in this fituation, no re- 
medies prove fo ufeful as thofe which in" 
vigorate and rellore the tone of the con- 
llitution. 

With this view, the patient fliould be 
l^efired to live upon nourifliing food* 

m 



SeO:. IV. and Contufed Wounds. 127 

He fliould be allowed as large a quantity 
as he can take, of good wine, or of ftrong 
mak-Hqnor, or of both ; and Peruvian 
bark (liould be given in as large do(es, 
and thefe fhould be as frequently re- 
peated, as his ftomach will permit. In- 
deed bark is perhaps the only remedy 
on which we can place any dependence; 
and as we know from experience that it 
may with (afety be given in great quan- 
tities, it fliould always be exhibited in. 
cafes of this kind without farther limita- 
tion than what neceflarily arifes from the 
ftate of the ftomach. We may remark, 
too, that it proves in general ufeful nearly 
in proportion to the quantity which is 
taken ; and it often happens, that large 
dofes are not more nauleated than thofe 
which do not contain above half the quan- 
tity. Where it is of importance to throw 
in a large quantity of the remedy m a 
fliort fpace of time, as is always the cafe 
in gangrene, it fiiould never be given 
in lefs than dofes of a dram, or even of 
two drams when the patient can bear it ; 
t 4 and 



128 Of Lacerated Ch. XXXVI. 

and thefe fliould be repeated every hour. 
Bark, in ibnie caies, feems to prove more 
powerful when conjoined with the vi- 
triolic acid : elixir of vitriol may there- 
fore be given along with it. In gan- 
grene ariling from debility, opium fre-^- 
qnently proves ufeful; and as it does not 
counteracl: the bark, the two remedies 
may with fatety be prefcribed together. 

In the mean time, the (late of the fore 
mud be particularly attended to. As 
long as there is any tendency in the con- 
tiguous parts to inflammation, the befl: 
applications, perhaps, are warm emolli- 
ent poultices and fomentations ; for, as 
we have elfewhere fliown, that the fepa- 
ration of mortified parts is commonly 
<sffe(fled by a fuppuration taking place 
between them and the adjoining found 
parts, we neceflarily derive moft: advan- 
tage from whatever tends to promote it*. 
But as no fuppuration will occur without 
fome degree of inflammation, when there 

is 

*F Vide Treatife on Ulcers, &c. Part L where this fubjeft 
~- |5 mprc fully confideredo 



Se£l. IV. and Contufed Wounds. 129 

is no reafon to imagine that this will 
otherwife happen, we fliould endea- 
vour to excite it by the application of 
warm dreffings to the fore, and efpeci- 
ally by the ufe of ftimulating fubftances 
to the contiguous found parts. Mu- 
flard applied in the form of a poul- 
tice, as well as fome others of the rube- 
facients, have proved ufeful in this man- 
ner ; and I have employed with advan- 
tase a ftrong; folution of crude fal-am- 
moniac in vinegar and water. It is pro- 
per, however, to obferve, that this prac- 
tice mud be managed with caution : for 
much inflammation might often prove 
detrimental, while in every inftance it 
would be unneceffary; for we know from 
experience, that a fmall degree of it 
proves always fufficient. As foon, there- 
fore, as it is obferved that the mortified 
parts are furrounded with a kind of in- 
flamed ring, the ftimulating applications 
fliould be removed in order to give place 
to warm emollients for the purpofes men- 
tioned above. Any parts that are com- 
pletely 



130 Of Lacerated Ch. XXX^L 

pletely mortified may with fafety be 
removed ; indeed the ofFen five fmell 
which they produce renders this a ne- 
ceflary meafure : but the common prac- 
tice of making incifions througli the 
difeafed parts into thofe beneatli which 
are flill found, fhould never be adopted. 
No advantage can be derived from it. 
and it may be prod udlive of much harm. 
It is recommended with the view of gi- 
ving more free accefs to the ointments, 
and other remedies ufed as dreffings, 
than could otherwife be obtained; but I 
have not in any inflance feen it prove 
ufeful, and in different cafes I have been 
fenlible of its doing mifchief. It may 
very readily carry the putrid matter of 
gangrene more deeply into the contigu- 
ous found parts than it would otherwife 
penetrate. In fbme cafes it has evidently 
induced more inflammation than was ne- 
cefFary ; and in more inflances than one 
I have known fcarifications prove hurt- 
ful, by exciting very troublefome hemor- 
rhagies. 

By 



Seft. IV. and Contufed Wounds* ' 131 

By perfifting in the ufe of bark, and 
of the other remedies we have juft men- 
tioned, and efpecially if the ftrength of 
the patient be fupported with wine and 
nourifliing food, even bad cafes of gan- 
grene will often terminate happily ; the 
mortified parts will feparate, and the 
remaining fore will heal kindly and ea- 
fily with common mild dreflings : But 
in other inftances, notwithflanding all 
our endeavours, the difeafe will conti- 
nue to fpread, and nothing will prevent 
its fatal termination. When gangrene is 
feated in any of the extremities, it is the 
common practice, when other means of 
cure fail, and when the mortification is 
Hill advancing, to amputate above the 
difeafed parts : we have elfewhere fliown, 
however, that this pratlice (hould not be 
adopted ; and when treating of amputa- 
tion, we fliall again have occafion to en- 
ter on the confideration of it. 

In the treatqient of mortification, it is 
a good general rule to be very fparing 
of every evacuation from the firft appear- 
ance 



132 Of Lacerated Ch. XXXVI. 

ance of the difeafe, and this efpecially 
with refpecft to blood-letting But in 
addition to what I have already obferved, 
I think it right to remark, that in all 
cafes of inflammation where the approach 
of gangrene is dreaded, and particularly 
in wounds attended with much contufion 
or laceration, till mortification adually 
occurs, we fhould proceed with freedom 
in an antiphlogiftic courfe, particularly 
in difcharging as much blood as the de- 
gree of inflammation may appear to ren- 
der necelTary ; and I infift on this point 
the more fully, from having often ob- 
ferved much mifchief enfue from pradVi- 
tioners being too timid in advifing it. 
Being afraid of finking the patient too 
much, they avoid the only remedy that 
could probably fave him : for, in fuch 
circum (lances, it is the violence of the 
inflammation of which we have moft rea- 
fon to be afraid; and as we know of no 
remedy which can with fuch certainty 
be depended upon for removing inflam- 
mation as blood-letting, it fliould be pre- 
fer i bed 



Seft. IV. and Contufed Wounds. 133 

fcribcd with as much freedom as the 
llrength of the patient and other cir- 
cumftances will permit ; by which the 
acceflion of gangrene will often be pre* 
vented when all the ufual remedies would 
probably fail. 

What we have hitherto faid in this 
and the preceding fedlions, may be con- 
fidered as common to wounds in gene- 
ral : We now proceed to confider thofe 
wounds, which, either from the nature 
of the part wounded, or from its fitua- 
tion, demand a peculiar treatment. 



S E C T I O N V. 

Of Wounds in the Veins. 



TT is difficult to reftrain the hemor- 
-i- rhagies which fometimes enfue from 
wounded arteries, on account of the 
force with which the blood is pro- 
pelled 



134 Of Wounds Ch. XXXVL 

pelled into them by the heart, and on 
account of their iiiufcular coats, which 
prevent them from coUapfing readily. 
But in the veins neither of thefe circum- 
flances take place ; the contra6lile power 
with which they are endowed is very in- 
coniiderable j and we do not perceive 
that the circulation in them is much af- 
fected by the a<flion of the heart. 

For thefe reafons, wounds in the veins 
heal with more eafe and are attended with 
lefs danger than wounds of the arteries : 
Indeed we know, that the largeft veins 
are often much injured, and that no bad 
fymptom will enfue j while very trouble- 
fome confequences will follow from 
•wounds even of fmall arteries. In ge- 
neral, therefore, we have no great reafon 
to be afraid of wounds in the veins : for 
■while we have it in our power to check 
the hemorrhagy, we never obferve any 
detriment to enfue even from the obli- 
teration of the largeft external veins ; for 
the anaftomofing branches {o readily ad- 
mit of dilatation, that they foon become 

fuffi- 



Seft. V. in the Veins. 135 

fufficienc for carrying on the circulation 
beyond the parts afFeded. 

We commonly find,.that a longitudinal 
cut in a vein heals with eafe when it is 
/lightly covered with a piece of dry lint 
or foft old linen : When this fails, the he- 
morrhagy may be always (lopped by the 
application of a piece of dry fponge or of 
agaric to the bleeding orifice, and fecu- 
ring it with moderate preiTure. But in 
tranfverfe cuts in the large veins, or when 
any of them are cut entirely acrofs, it may 
fometimes happen either that preflure 
cannot be properly applied to the wound, 
or that it does not prove fufficient for 
flopping the difcharge : In fuch cafes 
efcharotic applications are commonly 
advifed, and by fome pradlitioners the 
adlual cautery is employed ; but none of 
thefe can be depended on ; and they are 
apt to create a good deal of unealinefs. 
The fame remedy therefore fhould be 
employed here that we daily ufe in he- 
morrhagy from wounds in the arteries, 
namely, ligatures ; which, when pro- 
perly 



136 Of Wounds Ch. XXXVI. 

perly applied, neither fail in their effecls, 
lior produce any material inconveniency. 
In the application of ligatures, we have 
elfewhere fliown, that the crooked needle 
fliould feldom or never be iifed, and that 
the tenaculum alone fhoiiid be employ- 
ed. 



SECTION VI. 

Of Wounds in the Lymphatics. 

THE lymphatics are equally liable to 
Injuries with other parts of the 
body : As they often lie contiguous to 
veins, they are fometimes wounded in 
the operation of blood-letting ; and they 
are not unfrequently cut in opening bu- 
boes and other glandular collections of 
matter. 

When the fmaller branches only of 
lymphatics are opened, we may readily 

fuppofe 



Seft. VI. in the Lymphatics, 137 

ftippofe that they will heal along with 
the reft of the wound; but the wounded 
lymphatic is fometimes fo large, that ic 
does not heal ib loon as the other parts, 
but continues to pour out its contents 
in confiderable quantity, giving a good 
deal of inconveniency, and at the fame 
time weakening the patient : We fliould 
never heficate therefore in putting a flop 
to the difcharge. 

Various means have been propofed for 
effefting this. In fome cafes it has been 
done by compreflion alone : Aflringents 
have been advifed, together with the ap- 
plication of dry fponge, agaric, and of 
common puff-ball ; and both the aftual 
and potential cauteries have been ufed. 
But when moderate preffure fails, the 
mofl effed:ual remedy is the taking up 
the injured lymphatic with a ligature, in. 
the fame manner as we do wounded arte- 
ries. No objecTtion can be made to this ; 
and it anfwers the purpofe in the mofl 
certain manner. 

Vol. V. K SECTION 



Of Wounds of the Ch. XXXVL 



SECTION VII. 



Of Wounds in the Nerves and Tendons, and of 
Ruptures of the Tendons. 

T^ HEN treating of blood-letting, 
as well as in a preceding part of 
this chapter, I had occafion to fpeak of 
the confequences which fometimes enfue 
from partial divifions of nerves and ten- 
dons, and of the means which feem to be 
beft adapted for removing them. At 
prefent it might be fufficient to refer 
to thefe parts of the Work ; but I fliall 
now make a few additional obferva- 
tions. 

It mufl: often happen, that nerves and 
tendons are partially divided along with 
other parts ; but when no pain arifes frofn 
it, this accident does not particularly 
come under the obfervation of pra(5li- 
tioiiers. In fuch cafes they heal along 

with 



Se6:. VII. Nerves and Tendons* ♦ 139 

wicli the other parts of the wound : But 
in various inllances, either from fome 
fingular degree of irritability in the in- 
jured parts, or from a peculiarity of 
conrtitution, which we cannot explain, 
the flighteft pun(fture of a nerve or of a 
tendon, will induce very fevere pain, in- 
flammation, convulfions, and even death. 
Whenever we have reafon to fufpedt, 
from the violence of the pain, that the 
other fymptoms may fupervene, the nioft 
effedual means fliould be immediately 
ufed for preventing them ; for when 
once convulfions take place, we are never 
certain of being able to allay them. In 
fome cafes, large dofes of opiates an- 
fwer the purpofe : but when they do not 
very quickly prove fuccefsful, no time 
(hould be loft in putting the only remedy 
in pradlice, on which we can pla'^e much 
dependence ; and that is, the complete 
^ivifion of the injured nerve or tendon. 
By this we may indeed induce a certain 
degree of infenfibility in the parts be- 
neath, or they may even be deprived of 
K 2 the 



i4o Of Wounds in the Ch. XXXVI. 

the power of voluntary motion; but any 
inconvenience which this may occafion 
will be trifling, when compared with 
the advantages which refnlt from the 
operation : For I can from experience 
allert, that it feldom fails in removing all 
the fymptoms, wlien it is timeoufly em- 
ployed ; while, in clifFerent inflances, 
Avounds of this kind have terminated in 
death where it has been omitted. 

In this manner we may obviate the 
effedls of pundlures and partial wounds, 
either in the nerves or tendons : But 
it is necefTary to mention the method 
of treatment to be purfued in the heal- 
ing of wounds or ruptures of the large 
tendons, when they are completely di- 
vided. As a complete divifion of any 
of the large tendons is always at- 
tended with much retracflion, it was 
long ago inculcated by pra(5litioners, 
to draw the retrad:ed extremities of the 
ruptured tendon into contacf, and to 
retain them in this fituation by futures: 

and 



Se£l. VII. Nerves and Tendons. 141 

and this being done, and the limb placed 
in a favourable fituadon, the reft of the 
fore was treated in the ufual way. 

There is no reafon to doubt of cures 
having been often accompliOied in this 
manner : nay, where tendons have been 
merely ruptured, without any external 
wound, as often happens with the tendo 
Achillis, the retraced ends of the ten- 
don have been laid bare by an incifion, 
for the very purpofe of retaining them by 
futures. This, however, is a very pain- 
ful operation ; and as the fame intention 
may be accompliflied in a much more 
fimple manner, it ought to be laid aflde. 
When it was firft propofcd to unite rup- 
tured or wounded tendons by means of 
futures, it was the common opinion, that, 
in order to infure a reunion of divided 
parts, it was abfolutely neccfTary to bring 
them into clofe contaft ; and the fame 
idea prevailed, not merely with refpeft to 
tendons, but with regard to bones, as 
well as other parts. 

In the treatment of fraftured bones 
K 3 and 



i4i Of Wounds in the Ch. XXXVI. 

and of ruptured tendons, it is no doubt a 
right general rule to endeavour to bring 
the divided parts as nearly into contadl 
as poffible : but we now know that cures 
may be accomplillied where the retradlion 
of parts is fo confiderable as to render it 
impoffible to draw them together ; nay, 
that it has often been done, even where a 
portion of a tendon or of a bone has been 
completely removed. Very confiderable 
portions of bone hav been regenerated ; 
and although we are not certain that any 
part of a tendon has ever been renewed, 
yet fuch adhefions always take place be- 
tween the retradled ends of the divided 
tendon and the contiguous parts, as tend 
In a great meafure to fupply the deficiency. 
Thus I have known different inflances of 
th'e tendon of the rotula being ruptured, 
as well as of the tendo Achillis : and al- 
though the ends of the retradled tendons 
could never be brought within an inch 
of each other ; yet in all of them where 
proper attention was given, the cures 
]hi^?e been io far complete, that the ufe 

0^ 



Sed. VII. Nerves and Tendons. 143: 

of the limbs has been very perfeclly re- 
ftored. Some degree of ftiffnefs has of- 
ten indeed remained for a confiderable 
time ; but at la ft even this fymptom has 
very commonly been removed. 

Wherever a vsrounded tendon may be 
lituated, or even where it is only ruptu- 
red without any injury being done to 
the external parts, the limb fhould be 
placed in fuch a manner as will moft rea- 
dily admit of the retra(fted ends of the 
tendon being brought nearly together; 
and when in this ficuation, the mufcles' of 
the whole limb in'which the injury has 
happened muft be tied down with a 
roller in fuch a way as will prevent them 
from all kind of exertion during the 
cure, at the fame time that the parts are 
placed in fuch a pofition as will tend moft 
effedtually to keep them eafy and relaxed. 
Thus, in a wound or rupture of the ten- 
don of the redlus niufcle of the thigh, 
the patient's leg fhould be kept as much 
as poflible ftretched out during the cure, 
when the thigh fhould be in fome de^ 
K 4 gree 



544 ^I 'Woiinds_ in the Ch. XXXVL 

gree bent, fo as to relax the mufcle itlelf, 
as far as it can be done. While in fimi- 
lar affedions of the tendo AchilUs, the 
knee fliould be kept conflantly bent, fo as 
to relax the mnfcles of the leg as much 
as pofilble ; at the fan^e time that the foot 
jflioukl be (Iretched out, fo as to admit of 
the ends of the ruptured tendon being 
brought nearly into contad:. In apply-r 
ino- a roller to fecnre the mufcles and 
tendons in this fituation, it fhould be 
done with a firmnefs quite fufficient for 
the purpofe, at the fame time that care is 
taken to prevent it from impeding the 
circulation : with this view, fine foft flan- 
nel fliould be preferred either to linen or 
cotton : for being more elaftic, it more 
readily yields to anyfwelling with whici; 
the linib may be attacked. 

The late Dr Monro was the firft whq 
gave any accurate direc^lions for treating 
a rupture of the large tendons ; and he 
fias probably done it with the more pre- 
pifion, from having himfelf experienced 
|))e effeds of this misfortune in the tendo 

Achillis. 



Scci. VII. Nerves and Tendons. 145 

Achillis. As the metbod which he points 
out, and the hiftrumcnts which he recom- 
mends, are very fimple and judicious, 
and as they have in various inftances been 
found to anfwer very completely, a de- 
fcription of them will be confidered as a 
proper addition to this article. 

The different inftruments ufed by Dr 
Monro, with the feveral parts of each of 
ihem, are reprefented in Plate LXVIII. 

Fig. 9. Is a foot-fock or flipper, A, of 
double quilted ticken ; from the heel of 
which, B, the quilted ftrap, P, is of fuch 
a length as to reach above the calf of 
the leg. 

Fig. I. A ftrong quilted calf-piece, E, 
with pye-holes, FF, on each fide, through 
which a lace, fig. 2. is to be pafled, and 
with a buckle, G, fo placed on its back- 
part, that when the lacing is on the out- 
fide of the leg, the buckle will be in the 
middle of the lower part. Two rows of 
pye-holes are here reprefented, one on 
each fide; either of which may be ufed 
according to the fize of the les". 

In 



146 . Of Wounds in the Ch. XXXVI. 

In Dr Monro's cafe, the foot and leg 
were firft wrapped in foft flannel fmoaked 
with fumes of benzoin, when he put on, 
as in fig. 3. the foot-fock A and calf- 
piece E ; and bringing the ftrap H thro' 
the buckle G, he could by it extend the 
foot, and pull down the calf to what de- 
gree might be judged proper, and there 
it was fecured with the buckle. 

This bar.dage anfwered the intention 
perfe(5lly well ; and it was wore night 
and day. It fliould be drawn tighter 
during fleep, and relaxed when the pa- 
tient is awake and on his guard ; during 
which the foot fhould be placed upon a 
ftool, as at I ; and the calf-piece fhould 
be frequently fluffed, or made eafier by 
loofening the lace, fo as to prevent the 
foot from fwelling, which is apt to hap- 
pen if this be omitted. To prevent the 
toes from becoming uneafy, the foot- 
fock fhould be left open at the end K. 

During the firft fortnight the Dodor 
made no motion nor effort with his foot, 

but 



SeSt. VII. Nerves and Tendons. ■ 147 

but was carried in a chair, running on 
caftors, from one part of his houfe to an- 
other : After this he began to move the 
foot backwards and forwards, fo gently 
as not to give pain. In a gradual man- 
ner thefe motions were increafed ; the 
extenfion of the leg and flexion of the 
foot were always flopped on their produ- 
cing any uneafinefs. 

On beginning to walk, the affcded leg, 
which was the left, was always put be- 
fore the right, fo that the left foot might 
be as well extended as poflible. To pre- 
vent any danger from falling, a cane was 
ufed in the right hand. 

The void between the two ends of the 
divided tendon became infenfible in a 
few days, except that a foftnefs was felt 
there more than any where elfe ; but this 
part turned gradually thicker and harder, 
till a knot was formed in it of the fize 
of a middle-fized plum. At firft this tu- 
mor was equally hard with a piece of 
cartilage j but it gradually became fofter, 

andj 



148 Of Wounds in the Ch. XXXIV. 

and dimlniQied fo much, that at lafl: it 
was fcarcely perceptible. 

With a view to ftrengthen the leg and 
foot, cold water was poured upon them, 
and immediately thereafter they were 
well rubbed. This was firft employed 
fome weeks after the accident: bnt no ad- 
vantage being derived from it, the parts 
were afterwards llrongly rubbed twice 
a-day with unguentum altheae, or fome 
other emollient ; and this was continued 
till the limb could be ufed with free- 
dom. 

In about two weeks from the time of 
receiving the injury, the Doctor v\^as obli- 
ged to go abroad, when he ufed a pair of 
flioes with heels two inches high, and ap- 
plied the machine, which we (hall pre- 
fently defcribe, through the day, inftead 
of the former bandage ; which, however, 
was always put on at night for a month 
longer. 

This new machine, fig. 8. is a piece of 
fleel, the middle flalk of which, L, is 
narrow but llrong ; the ends, MM, are 

thin 



Sefl:. VII. Nerves and Tendons. 149 

thin and concave, and muft be adapted 
to the conveKity of the foot and fore- 
part of the leg. Three ftaples, a^ a, <?, 
ftand up from the fore-part of the flee! ; 
one in the middle of each of the broad 
ends, and the third in the middle of the 
(talk. All the (leel, except the (talk, 
fliould be covered with foft leather, and 
the concavities of M M fhould be well 
buffed, as the fofter rupture-bandages 
commonly are. 

After putting on the flioes and (lock- 
ings, one end of this machine was put 
upon the broad part of the foot, nearer 
the toes than the buckle of the fhoe, and 
the other end was placed upon the fore- 
part of the leg ; then one ribband, or a 
thong of leather, fig. 5. was put round 
the foot, and another, Hg. 6. round the 
leg, to pafs through the two ftaples near 
the ends of the machine, and there fecu- 
red with ftraps or buckles, but without 
being drawn tight. A third ftrap or 
ribband, fig. 7. with its middle, N, ap- 
plied to the hollow of the foot, immedi- 
ately 



150 Of Wounds in the Ch. XXX Vf. 

ately before the heel, had its ends paf- 
fed on each fide of the foot through a 
noofe, 0, of a fourth thong of leather, 
P, that came round the quarter-heel of 
the flioe, to be afterwards put through 
the middle ftaple ; where, after thefe 
ends, q q, were drawn as tight as was 
thought convenient for extending the 
foot, they were fecured with the buckle 
or with knots. See the application of 
this machine tin figure 4. 

This was continued for the fpace of 
five months ; but thofe who may find 
it inconvenient, might u(e inftead of it a 
thong of leather, fewed at one end to the 
tipper and middle part of the quarter- 
heel of the ftioe, and faftened at the other 
end to a garter or (trap put above the 
calf of the leg. The high-heeled ftioes 
were continued for a confiderable time : 
two years elapfed before they were 
thrown afide ; by which means, and by 
ti'eating the injured limb during all that 
period with great caution, a very complete 
cure was obtained ; while others, who 

have 



Sed. VII. Nerves and Tendons. 151 

have not been fo attentive to the ma- 
nagenient of matters of this kind, have 
not been ^o fortunate ; fome of them ha- 
ving the tendon ruptured a fecond, or 
even a third time, and others remain- 
ing ftifF and lame for a great length of 
time. 



SECTION VIII. 
Of Wounds in the Ligaments. 

"DY Ligaments we underftand thofe 
flexible bodies which ferve to co- 
ver the. different articulations, and by 
which many of the bones are firmly 
tied to one another. The bones of 
the pelvis are united by ftrong liga- 
ments ; and we know, that feveral other 
bones are chiefly conneded by the fame 
means. But as all thefe ligaments lie 
deep, they are not much expofed to the 
effeds of external violence ; and the 
fame caufe puts it out of our power to ap- 
ply 



/ 



1 52 Of Wounds Ch. XXXVI, 

ply any particular treatment for injuries 
which may accidentally be done to them. 
Our obfervaLions at prefent are therefore 
chiefly applicable to wounds of the liga- 
ments of joints, commonly termed Cap- 
fular Ligaments. 

As the ligaments are not fo plentiful- 
ly fupplied with nerves as fome other 
parts of the body, feveral anatomiils have 
been induced to believe that they are 
not poflefTed ,^of fenfibility ; by which 
we might be led to conclude, that inju- 
ries done to them would not probably 
require much attention : But although 
Nature for obvious reafons has not made 
the ligaments highly fenfible ; and altho* 
in a healthy (late they will bear much 
fatigue without fuffering fo much as 
other parts of the body ; yet the fa(5t is 
undoubted, that they are rendered ex- 
tremely fenfible by difeafe ; and that 
wounds inflidled on them are frequently 
productive of very alarming confequen- 
ces. We have often indeed known the 
ligaments of joints much injured, nay 

violently 



Seft. VIII. in the Ligaments. 153 

violently lacerated, by the heads of the 
bones which they furround being puilied 
through them, as well as by other caufes, 
without any bad efFcd: being experienced 
from it; and in fume cafes the wounds 
have healed as eafily as if the ligaments 
had not been affected. Thefe, however^ 
are rare occurrences, and are by no 
means to be depended upon : for in a 
great proportion of cafes where joints 
are wounded, the fymptoms which en- 
fue are fevere and hazardous. Affec- 
tions of this kind, however, arc very de-* 
ceiving: for In general nothing alarming 
appears at firfl:, nor for feveral days after 
the accident ; and when the patient is 
' treated with care and attention, I have 
known a week pafs over before any other 
fymptom has been obferved than what: 
ufually takes place in the mofl flmple 
wounds. But, at length, the patient be- 
gins to feel an uneafy fenfation of ftiff- 
nefs over the affeded joint, which by de- 
grees turns more fevere ; when the parts 
become fwelled, tenfe, and fomewhat 
Vol. V. L inflamed. 



154 ^f Wounds Ch. XXSVI. 

inflamed. In this fituation the pahi is 
in general fo very fevere, that the pa- 
tient cannot allow the joint to be touch- 
ed : He complains of a tiglitnefs round 
the whole, as if it was firmly tied or 
girded ; and the Inflammation, which at 
firft was confined to the joint itfelf, is 
now apt to fpread over the whole limb. 

If the wound or laceration in the cap- 
fular ligament is large, the fynovia is of- 
ten difcharged in confiderable quantities 
at firft ; but the fweliing induced by the 
inflammation gradually puts a flop to it, 
till at laft the wound becomes dry and 
floughy. In the courfe of a few days, 
however, extenfive fuppurations begin 
to form over the joint ; and on theie be- 
ing laid open, large quantities of pus are 
difcharged together with fynovia. By 
this the tenfion and girding pain are im- 
mediately removed, and the patient ex- 
periences much relief; but fucceflive fup- 
purations often take place, which from 
time to time excite a renewal of all the 
fymptoms, and by which the patient's 

health 



Seft. VIII. in the Ligaments. 155 

health is at lafl. very apt to be much in- 
jured. 

When wounds in the ligaments do not 
heal quickly, and almoft without the 
formation of matter, this is in general 
the manner in which they terminate ; at 
leaft it is the cafe in the larger joints, 
and it is in thefe chiefly that they ever 
prove alarming. 

From this hiftory of the rife and pro- 
grefs of the fymptoms, fbme advantage 
may be derived in condudling the cure. 
From this it is evident, that it is not mere- 
ly the injury done to the ligament which 
we have to dread, but a fecondary train 
of fymptoms, which are very apt to re- 
fult from it, Altho' none of the lining; 
membranes of cavities, which are natu- 
rally fliut up from the air, feem to be en- 
dowed with much fenfibility, it feems to 
be a very common effedl of air finding 
accefs to them to give them an exquifice 
degree of it. Of this we have frequent 
proofs in wounds which penetrate the 
pavities of the thorax and abdomen; and 
L 2 • it 



156 Of Wounds Ch. XXX VL 

it is evidently to this caiife that we are 
to attribute thofe confequences which 
refult from wounds in the capfular liga- 
ments of joints. 

This points out a very important cir- 
cumftance in the treatm.ent of fuch 
■wounds ; namely, the prevention, as far 
as is in our power, of air finding accefs 
to thefe cavities. In large lacerated 
wounds this will, for the mofl: part, be 
impradlicable ; but in common incifed 
wounds, it may often be very complete- 
ly effecHied. 

It ought never to be attempted, till wc 
are certain that any extraneous body 
that may have been carried in is extra(5t- 
ed. This being accompUQied, we may 
very commonly cover the wound in the 
capfular ligament entirely, by pulling the 
fkin fb far over it, that the wound in the 
one may not correfpond with that in the 
other ; and as the fkin about the joints 
is fufficiently lax to admit of this, it may 
always be eafily done. We are now to 
fix the fkin in fuch a manner that it may 

not 



Sect. VIIT. in the Ligaments. 157 

not retradl, either by futures or adhefive 
plafters : but in general the latter will 
prove fufficient, if they be aflifted by the 
application of a proper bandage ; and 
they are preferable to futures, which in 
this fituation are apt to excite inflam- 
matioii. After the pl^fteri are ap- 
plied, the fkia and cellular fubftance 
fliould be fupported in their fituation by 
paffing a flannel roller fpirally roiin the 
joint, fo as to produce an equal degree 
of comprelTion over the whole of it, of a 
tightnefs fufEcient for fupporting the 
pares to which it is applied without in- 
terrupting the circulation. The patient 
fhould be in bed while the dreflings are 
applied, fo that they may not afterwards 
be liable to be moved ; and the limb 
fhould be put upon a pillow, and plared 
in fuch a fituation as admits of the fkin 
and other teguments being mort com- 
pletely relaxed, which will be found to 
be different in different parts even of the 
fame joint. Thus, in treating a wound 
of this kind in the anterior part of the 
L 3 knee, 



158 Of Wounds Ch. XXXVI, 

knee, the leg fliould be kept extended du- 
ring the whole progrefs of the cure ; for 
in this fituation the (kin which covers the 
fore part of the joint is moft effedually 
relaxed ; while, for a fimilar reafon, in 
penetrating wounds entering from the 
ham, the leg Qiould be kept bent* 

In the mean time, in order to prevent 
the accedion of inflammation, the patient 
fhould be put upon a low diet ; his 
bowels fhould be kept lax ; a moderate 
perfpiration fliould be excited ; and he 
fliould lofe a quantity of blood fuited to 
his age and ftrength. 

By treating wounds of the joints with 
this ftrift attention, I have known many 
of them terminate eafily, which might 
otherv/ife have been produdive of much 
diftrefs : But when thefc means do not 
prove effedual, or when they have been 
too long neglected, fo as that the appli* 
cation of them is no longer admiflible, 
and which will always be the cafe when 
inflammation has taken place, other re- 
medies muft of courfe be employed* 

In 



Sed. VIII. in the Ligaments. i^g 

In this Situation, our principal objedl 
Is to remove the inflammation ; and if in 
be not fpeedily accompllflied, it will in 
all probability fpread over the whole 
joint, when it very commonly terminates 
in extenfive fnppurations. Every prac- 
titioner will know, that fuch an occur- 
rence is necefl^arily attended with much 
hazard ; Co that nothing (hould be omit- 
ted by which it can probably be prevent- 
ed. The moft effe^ual remedy which I 
have ever employed, is local blood- ' 
letting ; but, in order to prove ufeful, 
it muft be carried to a confiderable 
length. In ftrong robufl patients, eigh- 
teen or twenty leeches fliould be applied 
as near to the part afFeded as they will 
bite ; to be repeated daily as long as the 
continuance of the inflammation may 
render it necefl:'ary. Any of the fimple 
ointments may be applied to the wound 
itfelf ; but one of the befl: applications to 
the joint is the fleams of warm vinegar, 
ivhich have often appeared to prove ufe- 
ful in preventing the formation of mat- 
ter. 



j6b Of Wounds Ch. XXXVI, 

ter. And as the pain in wounds of the 
joints is in general fevere, large dofes of 
opiates muft be given to allay it. In a 
few cafes, I have known the pain much 
relieved by the external application of a 
ftrong deco6lion of white popy-heads by 
way of fomentation : but tor the moft 
part, nothing proves efFedlual but the in- 
ternal ufe of opium. 

By due attention to thefe means they 
will commonly prove effectual, if they 
have not been either too long neglede4 
or too fparingly adminiftered. From ei- 
ther of thefe caufes, however ; from the 
vicJence of the injury ; or from fome con- 
ilitutional afFe(5lion ; the inflammatioqi 
•will, in fome cafes, flill proceed to in- 
creafe; and, notwithflanding all our en? 
deavours, will at laft terminate in very 
large co:;edions of matter, which will 
be partly within the capfular ligament of 
the joint, partly in the fubflance of the 
Jigament itfelf, and in part it will be 
found to have fpread through the cellu- 
lar fubftance of the contiguous parts. In; 

fucl| 



Se£t. VII, in the Ligaments. i6i ■ 

fuch circumftances, all that we can do is 
to oive tree vent to any matter that may 
form ; which can only be done by ma- 
kino- an opening in the mod depending 
part of the colleJUons as foon as the exift- 
ence of pus is afcertained. In this man- 
ner, and by proper ufe of emollient poul- 
tices and fomentations whenever a nev\r 
collecftion appears to be forming, we will 
fom climes be able to fave limbs, which 
otherwife it would be necefTary to am- 
putate : But whoever has had experience 
in this branch of practice will know, 
that when wounds in any of the larger 
joints terminate in fuppuration within 
the capfiilar ligaments, that the riik at- 
tending them is great ; and ihat we can 
never, even under the beft management, 
have any dependence on their termina- 
ting favourably. The principal reafon, 
as we have already obferved, of their 
continuing obftinate, is the inflammation 
becoming violent ; which when not obvi- 
ated by the means we have adviled, is 
apt to produce fuch large colledtions of 

matter ; 



1 62 Of Wounds Ch. XXXVL 

matter ; and one abfcefs is fo apt to fucceqd 
to another, that the patient is at laft ex- 
haufted, when we are often under the 
necefiity of removing the limb in order 
to fave his life. In fuch circumftances 
indeed, there is no room to helitate ; for 
when the flrength is much impaired by 
the frequent formation of abfcefles, if the 
fame difpofition continues, and efpecially 
if any degree of hedic fever has taken 
place, the rifk attending any attempt to 
fave the limb will now be confiderable, 
while the chance of fucceeding will be fo 
fmall, that it fhould never be advifed. 

But although I am decidedly of opi- 
nion, in circumftances fuch as we are 
confidering, thsft it is the fafeft courfe to 
amputate the limb ; yet I by no means 
agree with thofe who fay, that almoft 
every cafe of a wounded joint requires 
the fame remedy. By many it has been 
afferted that wounds in any of the lar- 
• ger joints almoft univerfally terminate 
fo unfavourably, that, in order to fave 
OQUch pain and trouble, as well as rifk to 

the 



Se£t. VIII. in the Ligaments. 163 

the patient, it would be the moft advife- 
able pradlice to amputate immediately 
after the accident, before there could be 
any chance of inflammation taking place. 
I am convinced, however, that this opi- 
nion is founded in error ; and my reafons 
for it are thefe : 

Although it will not often happen that 
complete cures are obtained where the 
capfular ligaments of any of the larger 
joints are extenfively wounded, yet in 
fome cafes it is otherwife. Of this I have 
met with different inftances : And altho' 
fuch injuries will not often be fo effedu- 
ally cured as to prevent a confiderable 
degree of ftiffnefs and immobility in the 
joints in which they are feated ; yet even 
a complete anchylofis is an inconveni- 
ence to which a patient fhould fubmit, 
rather than to the pain and hazard which 
uniformly attend the amputation of any 
of the extremities. 

As it muft be admitted, however, that 
the proportion of limbs which are faved 
by this pra<5lice, is extremely fmall when 

the 



1 54 Of Wounds Ch. XXXVI. 

the injury done to the capfular Hgaments 
of joints are extenfive, this argument 
would not deferve our attention, if the 
delay which it occafions were to be at- 
tended with any additional hazard, or if 
it (hould preclude ampuration, if at any 
future period of the fore it might be jud- 
ged advifeable. This . indeed has been 
alledged by pradlitioners : but there is 
much caufe to fufped that they are 
wrong ; for many who have been accu- 
ftomed to amputate in the late ftages of 
fuch fores, have had more fuccefs than 
generally attends the practice when ad- 
vifed immediately after the injury is in- 
fli<5led. And this, in the courfe of my 
experience, has been fo uniformly the 
cafe, that fcarcely any have died who 
were not ptevioufly io very much redu- 
ced as to render their chance of recover- 
ing very fmall indeed ; a fituation which 
we have it always in our power to guard 
againft, by advifing the meafure before 
matters are fo far advanced* 

Where 



Seft. VIII. in the Ligaments. 165 

Where the capfular ligament of a joinc 
has not only been wounded, but much 
lacerated and contufed, it may in a few- 
cafes be proper to advife immediate am- 
putation. But fuch inftances are ex- 
tremely rare ; fo much fo indeed, that I 
have never met with any, excepting 
where the ends of bones have been j3er- 
haps much broke, and even fplintered at 
the fame time. Where this has not been 
the cafe, I have uniformly been in the 
pradlice of attempting to fave the limb ; 
and as in feveral inftances I have fuc- 
ceeded. without adding to the rilk of 
the patient where the trials have failed, 
I (hall certainly think it right to conti- 
nue it. 



SECTION 



i66 Of Wounds Qh. XXXVL 

SECTION IX. 

Of Wounds in the Face. 

TN the third volume of this Work, we 
entered into a full confideration of 
wounds of the head, which either pri- 
marily or eventually may affedl the 
brain: and in it, and in the fourth vo- 
lume, we treated of the Difeafes of the 
Eyes, Nofe, and Mouth ; we (liall now 
therefore refer to what was then faid 
upon thefe parts of our fubjetH:. 

In the treatment of wounds in any 
part of the face, one important objedl 
is to prevent deformity. This is indeed 
an obje(ft in every part of the body ; but 
in the face it is fo eflentlal, that the 
flighteft injuries done to It require parti- 
cular attention. 

As every cicatrix produces fome de- 
gree of deformity, we fliould endeavour, 

in 



Se(Sl. IX. in the Face. 1^7 

111 every wound of the face, to have the 
divided parts laid as exaflly and neatly 
together as pofUble, and to retain tlieni 
by thofe means which will be producHrive 
of the lead mark. In all fuperficial 
wounds in the face, as well as in thofe 
which run deep, when of a longitudinal 
diretlion with refpecT: to the fibres of the 
injured part, we fliould truft to adhefive 
plafters alone for retaining them. But 
Avherever the edges of a wound retrad: 
much from each other, as we will not be 
able in any other manner to retain them, 
futures ought without hefitation to be 
employed ; and of thefe the twifted fu- 
ture, defcribed in Chap. I. Sedl. V. Vol. I. 
ought in general to be preferred ; for It 
prevents retradion with more certainty 
than the others, at the fame time that it 
is not produdtive of more pain or uneafi- 
nefs. In this manner it is more efpecially 
uecelTary to treat all wounds of the lips, 
which cannot indeed in any other way 
be prevented from leaving much defor- 
mity : we ftiall refer, however, to the laO: 

volume 



1 68 Of Wounds Ch. XXXVL 

volume of this Work for what was far- 
ther faid upon this point when treating 
of the operation for the Hare Lip. 

Wounds in the cheeks are apt to pe- 
netrate the falivary dufts leading from 
the parotid glands ; and as this is fre- 
quently produdlive of much inconveni- 
ence, by the divided du(5l continuing to 
pour out the faliva long after the reft of 
the wound is healed, it becomes an im- 
portant objed in many inftances to ac- 
complifli a cure. But as we entered into 
a particular confideration of this point in 
the fourth volume of this Work, chapter 
XXX. Sedt. XIV. we muft now refer to 
what was then faid upon it. 

In the fore-head, wounds are fome- 
times attended with hemorrhagies, which 
prove troublefome from our not being 
able in the ufual manner to apply liga- 
tures upon the arteries from whence 
the blood is difcharged, owing to their 
running in a groove of bone ; which is 
the cafe with a fmall branch which 
palTes out on each fide from the internal 

carotid 



Sea. IX. in the Face, 169 

carotid immediately above the eye- 
brows. In all'fiicli cafes, we (liould, 
ill the firft place, employ fponge, agaric, 
or any mild aftringent, along with gen- 
tle comprellion ; and when this fails, we 
may endeavour to pull out the bleeding 
vefTel by means of the tenaculum, and in 
this manner may tie it with a ligature. 
I once fucceeded in this way with per- 
fect eafe, when every other method had 
been tried in vain. 

It may fometimes happen, however, 
that even this will fail. In fuch cafes, 
when the hemorrhagy continues fo pro- 
fufe as to endanger the patient, it may be 
proper even to remove that portion of 
the fkull In which the vellel is incafed ; 
or, in the hands of a nice operator, the 
intention may be anfwered by taking a- 
way the outer table of the fkull only : 
for, in fome cafes, thefe arteries run for 
a confiderable fpace between the two la- 
mina of the bone ; and in fuch inftances 
our object may be accompliflied by the 

Vol. V. M re- 



1/3 Of Wounds in the Ch. XXXVL 

removal of one of them ; and thus 
the rifk of expoling the brain will be 
avoided. 



SECTION X. 

Of Wounds in the Trachea and Oefophagus. 

IT is neceflary in fome cafes to make 
openings into the trachea and cefo- 
phagus, for allowing food and air to pafs 
to the (lomach and lungs when thefe 
pafTages are obflru^led. We muft refer, 
however, for the method of effeding this, 
to Chapters XXIII. and XXIV. Vol. II. 
where thefe operations are particularly 
defcribed : At prefent we arc to confider 
the method of treating wounds in the tra- 
chea and oefophagus, inflidled in fome 
cafes by accident, but more frequently 
by defign ; as often happens where fui- 
cide is attempted. 

The 



Scft. X. Trachi'a and Oefophagus. lyj 

The trachea is feldoni divided longi- 
tudinally. Tranfverfe wounds running 
between two of the cartilages, of which 
it is compofed, are more frequent. In 
fome cafes thefe wounds are fjperficial, 
and only penetrate the anterior part of 
the tube ; in others, they run fo deep as 
to divide it entirely. 

In all longitudinal wounds of the tra- 
chea, a cure may be obtained by the ufe 
of adhefive plafters alone : the lips of 
the wound will be eafily brought toge- 
ther ; and as the retraclion will never 
be confiderable, a proper application of 
adhefive ph^fter will prove fu65cient for 
retaining them. In fuch cafes, there- 
fore, they {hould be preferred to futures ; 
and bandages are here inadmiflible, as 
they cannot be applied with luch tight- 
nefs as to have any effect upon the 
wound, without comprefling the trachea 
fo much as to impede refpiration. 

Even in flight tranfverfe wounds of this 

part, a cure may often be effected with 

adhefive plafters j and this efpecially, if 

M 2 , ihey 



172 Of Wounds in the Ch.. XXXVX 

they be affiled by a proper poftnre of 
the head, which ui every wound of this 
nature fliould be kept as much as pofTible 
bent down upon the bread:. Indeed, if 
this be not duly attended to, it will of- 
ten be impoHible to produce a right re- 
union of the divided parts either with 
plafters or any other means : It ought 
not therefore to be left in the power of 
the patient. The head fliould be fixed 
with a bandage ; and the moft fimple, 
as well as the m6fl: effecflual, method of 
doing it, is by putting a common night- 
cap upon the head, and a piece of broad 
tape or ribbon being fewed on each fide 
of it above the ear, it may now be pulled 
down and fixed as low as is necefTary, by 
tying the tapes to a circular roller put 
round the cheft. In this fituation the 
head fliould be kept for feveral days, till 
there is reafon to imagine that the parts 
are firmly united.' 

But in tranfverfe wounds of the trachea,, 
which penetrate deep, \ve fliould not 
truft to adhefive plafters ; the interrupt- 
ed 



Seft. X. Trachea and Oefophagus, 1 73 

ed future made with broad ligatures will 
anfvver better. I am doubtful, however, 
if the ligatures fhould ever be palled into 
the trachea, as fome have advifed ; for the 
irritation and cough which they excite 
is very apt to do mifchief, by tearing a- 
funder the very parts they are meant to 
unite ; at leaft this has been the cafe in 
two inftances where I have known this 
method pradifed. A troublefome cough 
was induced in each of them ; the flitches 
were tore out ; and much perplexity was 
thus given both to the patient and fur- 
geon, 

Inftead of palling the ligatures round 
any of the cartilages of the trachea, and 
thvis carrying them into the cavity of the 
tube, I have in different inftances fuc- 
ceeded, merely by external ftitches done 
in the following manner : The furgeon 
being provided with a number of needles 
and ligatures, according to the extent of 
the wound, and the patient being pro- 
perly placed, one of the needles Qiould be 
inferted at one fide of the wound, and 
M 3 be* 



J 74 Of Wounds In the Ch. XXXIV. 

being palTed flowly up for the ipace of an 
inch between the trachea and fkhi, fo as 
to include all the cellular fubftance and 
miifcular fibres which lie between them ; 
. it is now to be pulhed out along with one 
end ot the ligature ; and die other extre- 
inicy of the thread being likewife armed 
with a needle, vcxxsW in like manner be 
pafTed through the tegumrnts of the op- 
pofite iide. Nont of the ligatures fhould 
be tied till they are all introduced ; when 
this is done, and the divided e dues of 
the cut are properly fupported by an af- 
fillant, tney Ihould be fecured with run^ 
ning knots, fo as to admit of their being 
eafiiy untied if this Ihouid be found ne- 
celfary ; adnelive pla Iters (hould be ap- 
plieds over the whole ; and the head 
fhouid be firmly fecured in the manner 
we have mentioned. 

i\\ palling the ligatures, care fliould be 
taken to run the needles as dole to the 
cartilages of the trachea as poflible, fo as 
to include whatever may afford them any 
liipport : For which purpofe fliit needles 

ftiould 



Seft. X. Trachea and Oefophagm. 175 

fhould be employed, with a flight degree 
of curvature, as is reprefented in Plate II. 

Whether or not this method will fuc- 
ceed where the trachea is completely di- 
vided, I cannot as yet determine, having 
had no opportunity in liich a cafe of put- 
ting it in pra<5lice : but as it has fucceeded 
where all the anterior part of the tube 
was divided, there is realon to imagine 
that it would not often fail. At any 
race, it fliould always be propoffd in the 
firft place; for ev£n when it does not 
fucceed, we are not prevented from em- 
ploying other means of relief. In fuch 
inftances we are reduced to the neceffity 
of paffing the ligatures round one or 
more of the cartilages of the trachea, 
which, with a curved needle, may be ea- 
fily done : Care fliould be taken, how- 
ever, to enter both ends of the ligature 
from the infide of the trachea,- when by 
pufliing the point of the needle out- 
ward, all rifk of doing mifchief will be 
avoided. 

M4 To 



176 Of Wounds in the Ch. XXXVL 

To give the pradlice as much chance 
as poffible of fucceeding, there fhould be 
as many ligatures introduced as may feem. 
in any degree necefTary for retaining the 
divided ends of the trachea together : In 
general, three flitches will be found fuf- 
ficient ; one in the middle of the promi- 
nent part of the trachea, and another on 
each fide, towards the extremities of the 
cartilaginous rings. 

Wounds of the cefophagus are to be 
managed nearly in the fame manner with 
wounds in the trachea : but they are 
more dangerous, on account of the diffi- 
culty of reaching the qefophagus from its 
deep fituation; from the under part of 
it, when entirely feparated from the reft, 
being apt to fall altogether within the 
fternum ; and from the difficulty of fup- 
portlng the patient with proper nourifh- 
ment. 

Thefe wounds are likewife to be con- 
lidered as dangerous, from their vicinity 
to large arteries and nerves. If the re- 
pun-ent nerves are divided, the voice may 

bjS 



Seft. X. Trachea and Oefophagus. 177 

be much impaired ; and if any of the 
large branches of the carotid arteries are 
wounded, the patient may die from lofs 
of blood before afliftance is procured. 

In wounds of the trachea and oefopha- 
gus, our firft objedl ftiould be to put a 
flop to the hemorrhagy, not only to pre- 
vent the lofs of blood, but to obviate the 
cough and ficknefs, which greatly ag- 
gravate the injury, and which are the 
confequence of blood' finding accefs to 
the ftomach and lungs. Every vefTel 
therefore that pours out blood, whether 
artery or vein, Ihould be immediately tied 
with a ligature. When the wound is not 
extenfive, but is confined nearly to the 
boundaries of the trachea and oefophagus, 
the artery which goes to the thyroid 
gland will probably be the largeft vef- 
fel that is cut ; for it is commonly in this 
fituation, immediately below the thyroid 
cartilage, that attempts are made upon 
the throat. But in wounds of greater 
extent, the jugular veins, and even the 
parotid arteries, are fometimes divided. 

For 



178 ^ Of Wounds in the Ch. XX'XVI. 

For the mod part, a wound in either of 
thefe ar *ics roves immedia.e ■, fatal; 
but when one of Mi. carotids is only par- 
tially hurt, there may be a poffibility of 
faving the piiient t)> fecuring the bleed- 
ing vefTel with a ligature both above and 
below the cut : at lead, it fhould always 
be attempted; and i i- probable, when one 
artery only is cut, that the attempt would 

j^ fucceed. There is no reafon to doubt of 
\ its proving fuccefsful^ in wounds of the 
jugular veins; but where thele veins are 
only wounded, without being cut entire- 
ly acrofs, we may with propriety endea- 

ft vour to effedl a cure by compreflion. 
"When flight compreflion only is ne- 
ceffary, it may be accomplifhed by a 
circular roller put round the neck ; but 
when any confiderable degree of preiTure 
is required, as this cannot be employed 
without impeding refpiration, we are un- 
der the neceflity of ufing a machine for 
protedling the trachea. In Plate LXIX. 
an inflrument is delineated, which an- 
fwers this purpofe very effedually. 

As 



SeOi. X. Trachea and Oefophagus. 179 

As foon as the hemorrhagy is flopped, 
we fliould proceed to unite thofe parts of 
the oefophagus which have been divided ; 
and in doing it, if the wound be not very 
extenfive, it will be of much importance, 
both to the operator and patient, to have 
it enlarged in every diredlion that may 
be necefTary for bringing the injured 
parts eafily and completely into view, by 
which the ligatures will be inrroJuced 
with much more exadlnefs than can o- 
therwife be done. In pafling the threads, 
the needles fliould be entered from with- 
in, and puflud outwards, in the manner 
we direcled for wounds of the trachea : 
and in both cafes, the ends of them 
fhould be left of a fufficient length to 
admit of their hanging freely out of the 
external wound in the teguments. The 
interrupted future appears to be beft 
adapted for this operation. 

In longitudinal wounds of the oefopha- 
gus there is reafon to imagine, from the 
refult of different cafes, that cures might 
frequently be accompliflied without the 

afTift- 



i8o Of Wounds Ch. XXXVL 

afliftance of ligatures. But in tranfverfe 
wounds of this part, it is the fafell prac- 
tice to employ one or more flitches, ac- 
cording to the extent of the injury, by 
which the food will be prevented from 
efcaping during the cure, and by which a 
reunion of the divided parts will be more 
readily accompliftied. 



S E C T I O N XI. 

Of Wounds in the Thorax, 

§ I . General Remarks on Wounds in the Thorav., 

nnO the confideration of wounds of the 
Thorax, it will be proper to premife 
a fliort account of the boundaries of this 
cavity, and of the vifcera which it con- 
tains. 

The thorax is an extenfive cavity, of 
an irregular oval figure, bounded ante- 
riorly by the fternum, laterally by the 
ribs, behind by the vertebrje of the 

back. 



Seft. XI. in the Thorax. • i8i 

back, above by the clavicles, and below 
by the diapliragm, a firm mufcular ex- 
panfion, which ferves as a partition be- 
tween it and the cavity of the abdo- 
men. 

The diaphragm does not pafs in a di- 
reft line from one fide of the chefl to jLhe 
other ; on the contrary, it falls confi- 
derably lower in fome parts than in 
others, by which the extent of this ca- 
vity is in different parts very unequal. 
On cutting the thorax diredfly acrofs a- 
bout the middle of the flernum, and 
looking down upon the diaphragm, we 
find it round and prominent about the 
middle, with its edges flretching down 
to its feveral attachments. In its high- 
eft and mod anterior point, it is fixed to 
the cartilago enfiformis ; from whence 
it defcends obliquely, and is attached as 
it goes along to the feventh, eight, and 
all the inferior ribs; while, behind, it 
is fixed to the upper vertebras of the 
loins. From this it is evident that the 
back part of the thorax is much more 

deep 



1 82 . Of Wounds Ch. XXX VI. 

deep and capacious than the anterior 
part of it : a point with which pradli- 
tioners fhould be very exadly acquaint- 
ed, othervvife their ideas of wounds in 
thefe parts will often be very erroneous. 
Thus, without this information, we would 
be apt to imagine that no injury would 
be done to the lungs by wounds running 
dire<5lly acrofs the body, after entering 
any part of the cavity of the abdomen : 
"whereas it is certain, that no inftrument 
can pafs in this diredlion even at the di- 
ftance of feveral inches beneath the up- 
per part of the abdomen, without pene- 
trating the cavity of the thorax; and, 
for the fame reafon, all wounds which 
pafs diredlly acrofs the body from the 
inferior and baqk part of the thorax, 
muft neceffarily pafs through the abdo- 
men. 

The whole cavity of the thorax is li- 
ned by a firm membrane termed the 
Pleura, which adheres every where to 
the fternum, to the ribs, intercoftal 
mufcles, and diaphragm. Each fide of 

the 



Scft. XI. in the Thorax. 183 

the chefl: has a dlftind pleura ; which 
uniting together near the middle of the 
breaft, and running tranfverfely from the 
fternum to the vertebrse, form two ca- 
vities which have no communication with 
each other. This membranous partition 
is termed the Mediaftinum. It adheres 
firmly, as one membrane, to the fter- 
num through its whole length ; but the 
two pleurae recede from each other near 
to the vertebrae, to admit of a pafTage for 
the aorta and oefophagus. The heart, 
inclofed in the pericardium, occupies a 
confiderable part of the left cavity of 
the thorax : the reft of this divilion, 
with all the right fide of the cheft, is 
chiefly filled wiih the lungs. The only 
other parts lodged in thp thorax are, 
the aorta, oefophagus, the thoracic du61:, 
thymus, and large blood-veflels about 
the heart. In a ftate of health, the lungs 
do not adhere to the pleura ; but it often 
happens, after inflammatory affedlions of 
thefe parts, that very firm and extenfive 
adhefions take place between them. 

The 



i«4 Of Wounds Ch. XXXVL 

The thorax is expofed to all the variety 
of wounds ; but the chief diflinftion we 
have to attend to, is that which takes 
place from their degree of depth. Su- 
perficial wounds, which do not run deep- 
er than the common teguments, if they 
are rightly treated, will feldom be pro- 
duftive of any important confequences ; 
while even the flightefl injury which pe- 
netrates the chefl: will, in fome inftan- 
ces, be attended with the mod alarming 
fymptoms ; and thefe again will be of a 
more dangerous nature when any of the 
vifcera lodged in the thorax are wound- 
ed. 

Wounds of the thorax may therefore 
be divided into three kinds : Thofe which 
affecH: the common teguments only ; fuch 
as merely penetrate the cavity, without 
doing any further injury ; and thofe by 
which fome of the vifcera are likewife 
hurt. 

Our firft objeifl in wounds of this kind 
is, to difcover whether they have pene- 
trated the cavity of the cheft or not ; 

which 



Se(fl. XL in the Thorax. 1 85 

which in general we may do by attend- 
ing to the following circumftances : By 
the patient being put into that fituation 
in which the wound was infiidled, and in 
this (late making a particular examina- 
tion with the fingers, or probe, of the di- 
retTion and deptii of the wound ; by the 
form of the inftrument, and the length 
to which it feemed to be puQied ; by any 
mild liquid which may be injecfled re- 
turning immediately or lodging in the 
wound ; by air being difcharged in con- 
jdderable quantities during refpiration ; 
by an emphyfematous (welling appearing 
over the contiguous teguments ; by the 
quantity of blood difcharged from the 
wound being confiderable or other wife ; 
by the appearance of the blood ; by 
blood being difcharged from the mouth ; 
and by 'the (late of the pulfe and relpira- 
tion. 

Each of thefe circumftances we (hall 
confider in the order they are mention- 
ed. 

It is obvious that it Is, of importance 
Vol. V. n' to 



i86 0/ Wounds Ch. XXXVI. 

to pay attention to the pofture of the 
patient during the examination of every 
wound ; but it is in none more fo than in 
wounds of the thorax, where, from the 
variety of mufcles which may be inju- 
red, and from the mobility of the ribs, 
■wounds may in one pofture appear to be 
quite fuperficlal, which In others are 
found to penetrate to a great depth ; for 
if any part of a rib, of a mufcle, or even 
of the cellular fubftancc, be forced by 
the pofture of the patient into the courfe 
of a w^ound, •neither the finger, probe, 
nor inje<ftions, will pafs with that eafe 
which the free examination of fuch in- 
juries requires. In all fuch cafes, there- 
fore, before we proteed to exaniine the 
dlretVion and depth of the wound, the 
patient fliould be placed as nearly as pof- 
fible in the podure he was in at the time 
of receiving it. 

In feme cafes, the opening is fo large, 
that we diftinguifli with the eye whether 
a wound has penetrated to the depth of 
the cavity or not; or we^ introduce ond 

of 



Seft. XI. in the Thorax. ?8; 

of the fingers, which is better than any 
probe, when it can be paffed forward 
without: lacerating the contifrnons parts ; 
but when the opening is too fmall to ad- * 
niit of this, we are under the necefiity of 
u(ing a probe; and the beftfiibftance for 
this pnrpole is a common bougie. Whea 
we mean by probing afore to difcover whe- 
ther there is any extraneous body lodged 
or not, or whether the bones beneath 
are carious or in a found (late, a metal- 
lic probe is to be preferred : but for ex- 
amining the depth and diredlion of a 
wound, nothing anfwers fo well as a firrn 
and tolerably thick bougie ; which nei- 
ther gives fo much pain to the patient, 
nor is it fo apt to be puilied beyond the 
depth of the wound into the contiguous 
loft parts, as the common fmall probe 
when ufed with freedom. This will not 
often indeed occur with praditioners of 
experience, as they will not only ufe 
this inltrument in every cafe with cau- 
tion, but will be fenllble that it is oftei> 
unnecefTarily employed : Fpr even in 
N 2 vvQundg 



i88 Of Wounds Ch. XXXVIo. 

v/ounds of the thorax, we fliould not 
fearch for their depth with too much 
anxiety ; as, by doing fo, more harm 
may be done than could be compenfated 
by any advantage to be derived from the 
difcovery. It is hig^lily proper to exa- 
mine, in a cautious way, into the di- 
reeTion and depth of fuch wounds ; but 
the yoiniger part of the profefTion fiiotild 
know, that much harm has been done 
by refearches of this kind being carried 
too far : and they (lionkl like wife know, 
that it is perhaps of more importance to 
be acquainted with the diredion of an 
external" pundured wound, which does 
not run deeper than the cellular fub- 
ftance above the ribs, or perhaps to. the 
jntercoflal niufcles, than to know, by 
means of the probe, whether a wound 
reaches to ^iie cavity of the cheft or not: 
for even where we find, in the moft evi- 
dent manner, that a wound goes to the 
depth of tills cavity, if no bad fymptoms 
occur, little or no advantage is obtained 
firom the difcovery; and wJiere fuch 

fymp- 



Sed. XI. in the Thorax. 189 

fyinpioms take place as are known to 
proceed from a penetrating wound, and 
of which we lliall afterwards treat, we 
are thus rendered equally certain of the 
nature o^ the cafe as if a probe had pafs- 
ed ealily into the thorax. 

Some advantage may be procured in 
inquiries of this kind, from our attend- 
ing to tlie fize and figure of tiie infl.ru- 
ment ; the diredion it fcemed to take; 
and the depth to which it was puflied : 
Thefe are points of which we cannot al- 
ways receive exad information ; but it 
is fometimes otherwife, particularly in 
duels, where a furgeon Is frequently at- 
tefiding, and where the byflanders are 
often fo much incerefted, as to be able to 
give diflincft intelligence upon this and 
every other point of importance. 

When we are rendered certain, by ei- 
ther of thefe modes of enquiry, of the 
depth of a wound, it would be unneceH- 
fary as well as improper to carry our 
refearches farther : but when the point 
remains in doubt, it may be fometimes 
N 3 de- 



s^c* , Of Wounds Ch. XXXVr, 

determined by throwinir in inje^T:ions 
6f any mild liquid. If the liquor re- 
turns immediately, there will be reafon 
to conclude that the wound is fuperficial, 
or at lead that it does not pafs into the 
thorax ; but when it lodges either alto- 
gether, or in any confideiable part, with- 
out raifing any outward tumefadion, 
there will be no caufe to doubt of its ha- 
ving reached the cavity. In throwing 
in liquids for this purpofe, either the 
common fyringe, Plate LXiV. fig. 4. may 
be employed, or a bag of the elaflic gum, 
motinted with a pipe as in Plate XXIX. 
fig. 3. but it fhould never be done with 
much force, as in this manner parts 
misht be tore afunder which were not 
previoufly hurt; and the mildell liquor 
only fhould be ufed, as it might prove 
datigcrous to apply any thing pofTelFed of 
stimulating powers to the furface of an 
irritable part. Honey and water are 
liiommonly ufed for this purpofe ; but 
^varm water alone is lefs irritating, and 
piould therefore be preferred. 



Sett IX. in the Thorax, 191 

When air is difcharged by the wound 
during infpiratlon, there will be caufe to 
ilifpec^l that the lungs are wounded. But 
although this is ufually confidered as one 
of the mod certain proofs of a wound ha- 
ving penetrated the cheft, yet it is pro- 
per to remark, that it is far from being 
decifive. Whereyer the lungs adhere to 
the pleura, a wound may penetrate to a 
confiderable depth; nay, it may pafs en- 
tirely acrofs the body, without entering 
what is properly termed the Cavity 
of the Cheft ; and we know that air is 
frequently difcharged at wounds in the 
thorax where there is no reafon tofufpedl 
that the lungs are hurt ; for when no 
adhefions take place between the pleura 
and lungs, the external air, if it gf^ts ac- 
cess by a penetrating wound, will pafs 
between them, and will necelTarily be for- 
ced out at every inl'piration ; a circum- 
ftance which invalidates the eertainty of 
this teft. In judging, therefore, of the. 
weight which is dxie to it, we Qiould, in 
the firft place, caufe the patient make fe- 
N 4 vera! 



1 92 Of Wounds Ch. XXX VL 

veral full infpirations, in order to dif- 
charge any of the external air that may- 
be colle6led ; and at the end of each, the 
contiguous fkin fhould be fo drawn over 
the wound, as to prevent any more from 
finding accefs. In this manner the whole 
will foon be evacuated ; when, if we flill 
find that air ruflies out during infpira- 
tion, we may with certainty conclude 
that the lungs are injured. 

Emphyfematous fwellings fometicaes 
appear, in confequence of wounds of the 
thorax, by the air from the lungs finding 
accefs to the furrounding cellular mem- 
brane. This, however, will feldom hap- 
pen in extenfive wounds ; as in thefe the 
air from the lungs will readily be dif- 
charged outwardly : but it is by no means 
unfrequent in pundured wounds, efpeci- 
aliy in fuch as have an oblique diredlion. 
It is obvious, however, that although this 
is a certain proof of the lungs being in- 
jured, that it may fometimes happen 
"Svithout any communication with the 

cavity 



Sea. XI. in the Thorax. 193 

cavity of the cheft, for the reafon men^ 
tioned in the laft paragraph. 

When the quantity of blood difchar- 
ged from thefe wounds is confiderable, 
we may with much certainty conclude, 
that they have not merely pafled into 
die chell, but that Ibme of the con- 
tained vifcera are wounded ; for, ex- 
cepting the incercoftal arteries, which 
run upon the inferior border of each rib, 
all the other blood-velTels of the exter- 
nal parts are here very fmall; and as we 
can by conipreffion eafily put a ftop to 
hemorrhagies from the intercoftal vef^ 
fels, we may in almoft every inftance 
difcover immediately whether the blood 
be evacuated from the chefl. or not. 

Even the appearance of blood difchar- 
ged fro^ thefe wounds may lead to a 
knowledge of their depth. It is a known 
fad:, that blood coming dired:ly from a 
wound in the lungs, has a more red, and 
particularly a more frothy appearance, 
than blood from any other part, owing 
probably to its being mixed witli the air 

in 



194 Of Wounds Ch. XXXVI. 

in the bronchiae ; fo that when blood 
afTimies this appearance, we have much 
caufe to conchicJe that the lungs are in- 
jured. 

When blood is fpit up by the mouth 
immediately after a wound in the tho- 
rax, there will be no reafon to doubt of 
the lungs being hurt. For although we 
ought not to conclude from the abfence 
of this fymptom, that the lungs have not 
fuffered, as they are often wounded with- 
out any blood being difcharged by the 
mouth ; yet we may be convinced, that 
fome injury is done to them when blood 
is adualiy difcharged from them. 

In our inquiries into the nature of 
fuch wounds, the flate of the pulfe and 
of refpiration fliould be particularly at- 
tended to. In wounds which 6f> not pe- 
netrate deeper than the common tegu- 
ments, neither the pulfe nor breathing 
are at firft affedled, nor do they produce 
any other confequences for the firft two 
or three days than wounds in any other 
part of the body : but wounds which go 

to 



Sect. XI. in the Thorax. 195 

to the depth of the thoracic cavity, and 
more efpeclally when they affedl the lungs 
or any other parts contained in it, may 
often be diflingulfhed by their producing 
an immediate effed both upon the pulfe 
and breathing. When the lungs are in- 
jured in a part where they adhere to the 
pleura, the wound may pafs to a confi- 
derable depth without any extravafation 
taking place into the cavity of the cheft ; 
in which cafe no immediate effe(5l may 
enfue : but when either blood or air finds 
accefs to this cavity, the lungs are imme- 
diately compreffed, by which the breath- 
ing becomes difficult, and the pulfe feeble, 
opprefTed, and intermitting; fo that when 
thefe fymptoms take place, we may at 
once give a decided opinion of the nature 
of the cafe. 

By due attention to thefe circumftan- 
ces, we may, in almoft every cafe of this 
kind, determine with much certainty 
whether a wound has reached the cavity 
of the thorax or not : and this being fix- 
ed, we are next to proceed to the method 

of 



£g6 Of Wounds Ch. XXX VI. 

of treatment. Wc fliall firft attend to 
thofe wounds which do not go deeper 
than the common teguments or mufcles, 
and Qiall afterwards treat of fuch as 
penetrate deeper. 

% 2. Of Wounds in the external Teguments of the 
Thorax. 



"When wounds of the thorax do not go 
deeper than the fkhi and cellular fubftancc 
they do not give any caufe for anxiety, 
as they heal with the fame eale, and are 
to be treated in the fame way, with fimi- 
lar wounds in other parts of the body : 
but when they reach the mufcular fub- 
ftance between the ribs, and efpecially 
when they run among tlieie parts for a 
confiderable way like iinufes, there is al- 
ways reafon to fear tliat at laft they may 
penetrate the cavity of the thorax ; for 
when fores in this fie nation are not in 
every refpert properly treated, and if any 
matter that forms in them be not regu- 
larly 



Se£t. XI. in ihe Thorax. IQ/ 

larly difcharged, it is very apt to pais 
deeper and deeper, till at laft it make its 
way through the pleura itfelf. In all fuch 
cafes, therefore, it (hould be the fidl ob- 
ject with practiuoners to give a free vent 
to the matter. In open incited wounds, 
all that is neceffary is, by means of foft 
eafy drelfings, to preferve their lips or , 
edges from adhering till they fill with'* 
o-ranulationsfrom the bottom : butpunc- 
tured wounds (hould either be laid open 
through their whole extent, or a feton 
lliould be pafled from one end of the 
finus to the other. When they are not 
very extenfive, the fliorteft and eafiefl: 
method is to lay them freely open with 
a fcalpel and director, and then to heal 
them from the bottom like incifed 
wounds from any other caufe: but when 
a pundure runs to any confiderable 
length, the method of cure by a feton 
anfwers better. By paffing a feton along 
the courfe of the finus, it is not allowed 
to heal outwardly till the whole be 
equally filled up; and this being accom- 

plilhed 



198 Of Wounds Ch. XXXVI. 

pUflied, if the cord be gradually dimi- 
nifhed, when it is at laft removed, a mo- 
derate degree of preiFure continued upon 
the parts for a tew days longer, will fel- 
dom fail to efFedl a cure. Some, indeed, 
ad vile us to attempt the cure of all fuch 
fores with preffure alone. But although 
this practice will often prove fuccefsful 
••'in other parts of the body, particularly 
in the extremities, where preflure can be 
applied with exadlnefs along the whole 
courfe of a finus, and be continued for a 
fufficient length of time without rifk ; 
yet in wounds of the thorax, the fame 
advantages are not to be expeded from 
it : for here the conftant motion of the 
ribs prevents us from applying a conti- 
nued equal prefTure without impeding 
refpiration in a very difagreeable man- 
ner. When a cure is to be attempted by 
preflure alone, it muft be done with a 
roller pafled firmly round the thorax, 
fupported by what is termed a Scapulary, 
put over the fhoulders : But when a fe- 
ton has been previoufly ufed, any pref^ 

fure 



Sedl. XI. in the Thorax. 199 

fure that is neceflary may be applied 
with flips of adhefive plafter laid along 
the courfe of the wound, and fixed upon 
the contiguous (kin. 

This method of cure, by laying the fi- 
nufes open, or by the infertion of a fe- 
ton, to thofe not much verfant in this 
branch of pradice, may appear to be un- 
necefTarily fevere ; for by many of the 
older writers we are told, that our ob- 
je£l may be accomplilhed in a much more 
eafy manner, namely, by keeping the 
external openings of the fores pervious 
by the ufe of tents till they are firmly 
healed from the bottom. In wounds 
which penetrate to the cavity of the tho- 
rax, tents, efpecially thofe of the hollow 
kind, prove often ufeful ; and as they 
may be ufed with perfe(fl fafety, they 
fhould not be fo generally condemned as 
fome modern praditioners have afFeded 
to do. But in pundured wounds which 
do not go to this depth, as our great ob- 
ject is to avoid every rifk of the matter 
finding accefs to the thorax, whatever can 

tend 



200 Of Wounds Ch. XXXVf, 

tend to impede the difchargeof It, fliould 
by all means be avoided. So that in fuch 
cafes tents (hould never be ufed ; they 
would frequently do much mifchief in 
the manner we have mentioned : in many 
cafes they would fail entirely ; and if 
they (hould ever fucceed, the cure would 
prove much more tedious, and often more 
painful, than the mode of treatment we 
have advifed. 

In every wound of any importance, it 
is proper to pay particular attention to 
the regimen of the patient; a point 
upon which the event of the cafe very 
often depends : For we frequently 
obferve Injuries of this kind treated 
in ev^ry other refpeft with propriety ; 
and yet the praftitioner fails, from the 
patient beingallowed too much freedom 
in food, drink, and exercife. In wounds 
of the thorax, attention to thefe points 
is ftill more necefTary than in fimilar af- 
fe<flions of any other part : for as the con- 
tained parts are highly necefTary to life, 
and as they are very liable to inflamma- 
tion, even from injuriesthat do not pe- 
netrate 



Sedl. XL in the Thorax. lai 

netrate deep, every precaution fhould be 
employed that can probably tend to pre- 
vent it. Hence, for feveral days at leaft, 
or even till there does not appear to be 
any farther chance of the parts becoming 
inflamed, the patient fliould be kept upon 
a low, cooling diet ; animal-food and 
ftrong liquors of every kind fliould be a- 
voided ; the bowels fhould be kept open 
with mild laxatives ; and when the pulfe 
requires it, a due proportion of blood 
fhould be evacuated. Reft of body and 
perfed quietnefs is of much importance 
in thefe wounds ; for they are afFeded by 
the leaft degree of motion ; even cough- 
ing, laughing, or much fpeaking, is apt to 
hurt them, and fhould therefore be as 
much as poftible avoided. 

§ 3. 0/" Wounds which penetrate the Cavity of the 
Thorax. 

Wounds penetrating the thorax are al- 
ways to be confidered as hazardous, and 
therefore merit the utmoft attention : 

Vol. V. O Even 



202 Of Wounds QM. XXXVI. 

Even fuch as merely penetrate the cheft 
are often attended with the mofl impor- 
tant confequences ; but the contiguity of 
the lungs and other vifcera adds much to 
the danger. At prefent, we are to treat 
of fimple penetrating wounds, not con- 
nedled with any injury done to the con- 
tained parts. 

It is now known, that in a ftate of 
health the lungs fill the fpaces allotted 
for them in the two fides of the thorax 
fo completely, that they are every where 
in contadl with the pleura both in the 
ftate of infpiracion and expiration : And 
it is alfo known, that great diftrefs in 
breathing is induced by air, blood, or 
any extraneous matter being admitted 
between them. Now, in penetrating 
wounds of the thorax, excepting where 
the lungs morbidly adhere to the pleu- 
ra, and which we do not here fuppofe 
to be the cafe, it is fcarcely pofiible 
to prevent both air and blood from 
being admitted : The external air rufli- 
ing in at the wound foon fpreads over 
the whole correfponding cavity ; and 

when 



Seel. XI. in the Thorax, 203 

when the intercoftal artery or any other 
blood-velTel is divided, if the external 
opening be not fufficiently large, any 
blood that is evacuated is very apt to fall 
down between the pleura and lungs to 
the very bottom of the cheft ; by which 
difficulty of breathing immediately takes 
place, along with all the other fymptoras 
which ufually attend a comprefTed ftate of 
the lungs. 

In Volume II. Chapter XXII. we have 
entered into a full confideration, not only 
of the fymptoms induced by the collec- 
tion of fluids in the cheft, but of the me- 
thod of relieving them by the operation 
of the paracentefis : To avoid repetitions, 
we fliould now refer to what was then 
faid upon this part of our fubjed, and at 
prefent fliall offer a few obfervations upon 
the means of preventing fuch collections 
as may require the afliflance of that opera- 
tion. 

In wounds which do not penetrate to 

the depth of any of the vifcera, but which 

merely pierce the pleura, almoft the on- 

O 2 ly 



204 Of Wounds Ch. XXXVT. 

ly artery which can be cut, that can af- 
ford any quantity of blood, is the inter- 
coflal ; and as it is of a confiderable fize, 
no time fliould be loft in fecuring it 
whenever it is found to be wounded. As 
it runs in a groove in the inferior edge of 
the rib, it is difficult to put a ligature 
about it ; but with attention this may al- 
ways be accomplifhed. 

In free incifed wounds, the bleeding 
orifice will be brought clearly into view j 
but in fmall pundured wounds, as the 
artery cannot be diPtindly feen, there is a 
rieceffity for laying the pairts fufKciently 
open with the fcalpel. When the artery 
is thus laid bare, various means have 
been propofed for fecuring it. For the 
reafon juft mentioned, a crooked needle 
cannot be paffed round it. We are there- 
fore told by fome, that the only method 
of doing it is to pafs a firm broad liga- 
ture altogether round the rib, and by 
means of it to tie a dofTil of lint upon the 
orifice in the artery ; while others con- 
demn this pra<fl:ice, from the injury which 

it 



Se6t. XI. in the Thorax. 205 

it muft neceflarily do to the pleura ; for 
this membrane can fcarcely be feparated 
from the rib, fo as not to be included in 
the ligature ; and different inflruments 
have therefore been propofed for obviating 
this inconveniency. The intention of all 
of them is to comprefs the intercoftal ar- 
tery, without hurting the pleura ; but as 
none of them I have met with anfwer 
this purpofe, I do not think it neceffary 
to delineate them ; thofe who wifh to fee 
them may look into the fecond volume of 
Memoirs of the Royal Academy of Sur- 
gery at Paris. 

It is luckily, however, in our power 
to fecure this artery in a much more 
limple manner. By dilating the wound 
fufficiently, we may with a tenacalum, 
fomewhat more bent at the point than 
ufual, draw the bleeding vellel out of its 
groove, fo as to tie it in the ordinary 
v/ay ; at leaft in thin people it may be 
eafily done : and where it is found, ei- 
ther from the ribs being deeply covered 
with fat, or from any other caufe, that 
O3 it 



3o6 Of Wounds Ch. XXXVI. 

it cannot be fecured in this manner, it 
may always be' done in the manner we 
have mentioned, by pafling a firm broad 
ligature round the rib, and by means of 
it tying a fmall doflil of lint upon the 
bleeding artery. In this way a portion 
of the pleura will no doubt be included 
in the ligature ; but it does not appear 
from experience, that this is produdlive of 
any thing bad ; and v<?ith fufBcient cau- 
■ tion we may always with certainty avoid 
the lungs. When the lungs do not ad- 
here to the pleura, they collapfe in fome 
degree immediately on the external air 
finding accefs through the wound to the 
cavity of the cheft. And even when they 
do adhere, we may eafily feparate as 
much of them with the point of the fin- 
ger as will admit of the pailage of the 
ligature. 

Vv'^hen a prajflitioner is called imme- 
diately, he may in this manner prevent 
any quantity of blood from being emp- 
tied into the thorax ; and as foon as the 
hemorrhagy is (lopped, he fliould endea- 
vour 



Seft. XI. in the Thorax. 207 

vour to expel all the air that has found 
accefs by the wound to the furface of 
the lungs ; for till this is accompiiihed, 
the breathing will remain opprelled, nor 
will the patient be able to bear the ap- 
plication of the necelTary dreffings. In 
the chapter above alluded to, we have 
mentioned different methods of expel- 
ling air from the furface of the lungs ; 
but the fimpieft and eafieft is this : While 
the wound yet remains open, let the pa- 
tient, in a flow gradual manner, make a 
full infpiration, by which a confiderable 
part oi: the colledled air will be difchav- 
ged. This being done, the flcin muft be 
inftantly drawn over the fore, fo as to 
cover it completely during expiration ; 
and if the wound be moderately opened 
during infpiratipn, the whole quan- 
tity will thus be foon expelled. Af- 
ter which the lips of the wound fhould 
be drawn exadly together, and in this 
fituation fliould be fecured by different 
flips of adhefive plafter, care being ta- 
ken to fupport the whole by a proper 
O 4 appli- 



2o8 Of Wounds Ch. XXXVI. 

application of the napkin and fcapulary 
bandage. 

In this manner wounds of the thorax 
■will frequently heal, which, if left to 
themfelves, or if treated in the nfual way 
by allowing them to remain open, might 
be produ6live of much diftrefs : But in 
fome cafes, either from a conliderable 
quantity of blood having been thrown 
out from the intercoftal artery before the 
ligature was applied ; from the oozing of 
blood from the fmaller ramifications of 
the intercoftal arteries ; or perhaps from 
a fubfequent formation ol: pus ; oppref- 
fed breathing v/ill fupervene, hotwith- 
ftanding all that can be done to prevent 
it. 

When this takeS place as a confequence 
of a wound in the cheft, from the forma- 
tion of matter, an opening fhould be 
made to difcharge it in the manner we 
have advifed in the chapter on Empyema; 
and in this cafe the opening fliould be 
made in che mofl depending part of the 
thorax. But when it occurs immediately 

after 



Se£l. XI. in the Thorax. 209 

after a wound, and while the blood yet 
remains in a fluid (late, we may often be 
able to dilcharge it at the wound itfelf : 
and when this can be done, it fhould 
always be preferred ; for we are not to 
imagine that the thorax can in any pare 
be laid open without fome rifle of harm 
being done by it. When fymptoms, 
however, of opprelled breathing occur 
from a wound in the upper part of the 
thoras, as wd will not be able to dif^ 
charge the blood by it, we are under the 
neceflTity of making a perforation in the 
•under part of the che(i as foon as they 
become in any degree formidable. It is 
proper, however, to obferve, that this 
operation fliould never be advifed while 
the fymptoms are xuoderate ; for we have 
daily inftances of fmall quantities, not 
only of blood but of other fluids, be- 
ing abforbed ; and as the rifle attend- 
ing a perforation in this place is proba- 
bly greater than that which occurs from 
fmall quantities of blood being allowed 
to remain, it Ihould not be attempted as 

long 



21© Of Wounds Ch. XXXVL 

long as the breathing continues tolera- 
bly free. 



§ 4. Q/" Wounds of the Lungs. 

We have already, in the courfe of this 
fedlion, enumerated the fymptoms which 
indicate a wound in the thorax to have 
penetrated the lungs : And although 
the danger in this cafe is greater than 
in wounds which merely penetrate the 
pleura, yet the method of cure fuited to 
the one is fo nearly the fame with what 
we have advifed for the other, that it is* 
fcarcely necelTary to enlarge farther up- 
on it. 

It is proper, however, to obferve, that 
as the ri(k attending wounds in the lungs 
is confiderable, the caution with which 
they are treated iliould be proportionally 
great. Inftances indeed have occurred 
of their healing with eafe and fafety ; 
but thefe are fo rare, that we do not he- 
fitate in faying, that every injury done 

to 



Se£t. XL '"« the Thorax. 211 

to them is to be confidered as hazar- 
dous. 

The danger which attends them origi- 
nates, in the firft place, from the hemor- 
rhagy being apt to proceed farther than 
the ftrength of the patient will bear ; and, 
afterwards, from abfcefTes forming in the 
lungs, which are apt to terminate in pthi- 
fical afFedlions. 

The hemorrhagy is moft readily check- 
ed by plentiful venefedlion, which in 
.fuch cafes fhould at once be carried fo 
far as to Induce fainting ; by the patient 
being kept in a cool apartment and at 
perfect reft ; by the ufe of cooling laxa- 
tive medicines ; and by a low regimen* 
Befides reft of body, it is of the utmoft 
importance to keep the lungs as free 
from adlion as poflible. Hence cough- 
ing, laughing, and even much fpeak- 
ing or deep infpirations, fhould be rigid- 
ly guarded againft. Attention to this 
point is neceffary in every wound of the 
thorax, but it is more particularly fo in 
thofe which afte^l the lungs ; for when 

this 



2 52 Of Wounds Ch. XXXVI. 

this vifcus is wounded, it can never be 
fully didended with air without ftretching 
every blood-veiTel that has been hurt. 

Notwithftanding, however, of our ut- 
moft attention, the patient will fometimeg 
fink under the lofs of blood ; in other 
cafes, blood will be colledled in confidera- 
ble quantities betwixt the pleura and lungs, 
fo as to impede refpiration ; or abfceffes 
will form, as we have obferved above, in 
the fubftance of the lungs. 

We have already confidered the method 
of treatment in colledions of blood feated 
between the pleura and lungs : at prefent 
we fliali offer a few remarks on the ma- 
nagement of abfceffes in the lungs. 

Matter colleded in the fubftance of the 
lungs from a wound, may be difcharged 
in three different ways. It may be fpit up 
by the mouth ; it may be difcharged by 
the abfcefs burfting into the wound itfelf; 
or it may be emptied into one or other of 
the cavities of the cheft between the lungs 
and pleura. 

When an abfcefs in this fituation opens 

into 



SeS:. XI. in the Thorax. 213 

into the bronchiae, there may often be 
fome rifle at firft of immediate fufFoca- 
tion ; but when this danger is over, by 
a confiderable quantity of the matter be- 
ing difcharged, if there is no conftitu- 
tional or hereditary pthifical tendency, a 
cure will often be accompHflied by the 
means ufually advifed in fuch cafes, 
namely, by a diet that i^ light and of eafy 
digeftion, and at the fame time fufEcient- 
ly nourifliing ; and by daily moderate 
exercife, by which any mat'ter collec- 
ted in fuch abfceffes is brought up with 
more eafc than by any other means. A 
fea-voyage too anfwers particularly well 
for this purpofe, at the fame time that 
it tends to brace and invigorate the con- 
flitution ; but when this cannot be ob- 
tained, we advife riding on horfeback. — 
When pus colleded in the lungs is dif- 
chacged in this manner, the bufinefs of 
a furgeon becomes altogether unneceffa- 
ry ; but when the abfcefs either enipties 
itfelf into one of the cavities of the cheft, 
or points outwardly at the wound, we 

have 



214 Of Wounds Ch. XXXVI. 

have it often in our power to fave the 
patient by an operation, when otherwife 
he would inevitably die. 

When an abfcefs burfts into one of the 
cavities of the cheft, the matter fhould 
be difcharged in the manner we have 
mentioned in the XXIII. Chapter above 
alluded to : But when the wound by 
which the colledlion is produced remains 
open, fo as to admit of the matter to 
point towards it, as foon as this is difco- 
vered, either by a fmall oozing of pus 
taking place, or by the introdu6lion of 
the finger between two of the ribs, we 
Ihould at once determine on treating it 
on the fame principles and in the fame 
manner with abfcefTes in any other part 
of the body, namely, by making an open- 
ing into it of a fufficient fize ' for dif- 
charging the matter. The delicate nature 
of the part in which the matter is feated 
may be a means of deterring fome from 
adopting this pracTbice ; but it does not 
require much argument to fhow, that a 
patient in fuch circumltaaces runs much 

more 



Seft. XL in the Thorax. 215 

more rifk of fufFering by the matter be- 
ing allowed to remain, than by ma- 
king an opening into the abfcefs. By 
the laft meafure he avoids the hazard 
of immediate death, which often hap- 
pens from large abfceffes burfting into 
the bronchiae ; at the fame time that it 
prevents the matter from paffing into the 
cavity of the cheft, between the pleura 
and furface of the lungs ; and thus obvi- 
ates the neceflity of a fecond operation. 
Nay, in cafes of this perilous nature, I 
would even go farther : When from a pre- 
vious difcharge of matter we are certain 
that an abfcefs has formed in the lungs 
as a confequence of a wound ; when a 
ftoppage of this difcharge takes place, 
and is fucceeded by all the ufual fymp- 
toms of a frefh collet^ion of matter, fuch 
as an increafed difficulty in breathing j 
difficulty in lying on the found fide ; fre- 
quent fhivering fits ; and a he<fl:ic pulfe ; 
as in fuch a fituation there will be no 
reafon to doubt of matter being colle<5l- 
ed, and as the patient muft remain in the 

utmoft 



2i6 Of Wounds - Ch. XXXVI. 

utmoft hazard till it be difcharged, I 
fliould think it advifeable to enlarge.tlie 
external wound not only of the common 
teguments, but of the intercoftal mufcles, 
and to extend the opening for the fpace 
of two or three inches ; by which more 
freedom will be given for fearching with 
the finger for the feat of the abfcefs : and 
whenever it is difcovered, I would not 
hefitate, at whatever depth it may be, to 
open it, by running a biftoury along the 
finger, and pufhing it llowly into it. In 
the courfe of my own experience I have 
had two cafes of this kind ; in which, by 
this decifive pradice, I had the fatisfac- 
tion of favlng two lives, which otherwife 
muft in all probability have been loft. 
This was the opinion of other pradli- 
tioners who attended along with me ; 
and I was fo much convinced, in both 
cafes, of matter being coUeded internally 
which produced the danger, and of no- 
thing being able to fave the patient 
but the difcharge of it, that after warn- 
ing the patient- of his ficuation, and re- 
ceiving 



Sedt. XI. in the Thorax. 217 

ceivi ng his approbation, I was refolved to 
carry the opening into the fubftance of 
tlie hmgs to the tuH dei|)th of my finper, 
rather than to leave him to his fate. In 
both indances I found it neceflary to go 
to nearly the length of my finger; and ac 
this depth I was lb fortunate as to reach 
an abfcel's containing at leaft half an 
Englifh pint of matter. The patients in 
both cafes were inflantly relieved; and 
although they were previoufly fuppofed 
to be in the utmoft danger, with fcarce- 
ly a poflibility of recovering, they are 
now, after fcveral years have elapfed, in. 
perfeft health. 

In making an opening into fucli a deep- 
feated abfcefs, the incilion ihould be 
carried forward in the mod gradual man- 
ner, fo that no more of the lungs may 
be injured than is altogether neceflary: 
But when once the matter appears, the 
abfcefs fliould be laid as freely open as 
may be proper for an entire difcharg<? 
of it. 

In the fubfequent treatment of an ab- 
YoL. V. . F j:cQi:$ 



2i8 0/ Wounds Ch. XXXVL 

fcefs of this kind, much attention is re- 
quired in preferving a proper aperture 
for the difcharge of any matter that may 
afterwards form in it : for if this be ne- 
glefted before the abfcefs is filled up from 
the bottom, a new colledion will foon 
take place, and the patient will be redu- 
ced to the fame (late of uncertainty and 
danger he was in before. In wounds 
which do not penetrate deeper than the 
teguments or mufcles of the thorax, we 
have obferved above, that no kind of 
tents (liould be employed ; and have ra- 
ther advifed them to be laid open thro' 
their whole length, or to be treated by 
means of a fcton, as we do fores of a fi- 
milar nature in other parts of the body. 
But as this is impracTticable in penetra- 
ting wounds, we are in thefe under the 
neceffity of inferting a tube into the 
opening, and of continuing it of a fuffi- 
cient fize and length during the whole 
courfe of the cure : it ought indeed to 
be continued as long as any matter is 
difcharged. Tubes of lead being more 

foft 



Se£l:. XI. 'in the Thorax. si^ 

Ibfc and pliable than thofe of any other 
metal, are therefore to be preferred : 
They fhould be broad, and of a round 
oval form rather than altogether round ; 
and they fliould always be furnilhed with 
a brhn coniiderably broader than the 
opening of the fore, to obviate every pof- 
fibility of their falling into the cheft. 
By inattention to this point, a tube of 
four inches in length, and of a corre- 
fponding thicknefs, palled altogether in- 
to the cavity of the breafl: of a gentle- 
man who had ufed it for fome time ; and 
notwithftanding various attempts to ex- 
trad: it, it ftill remains lodged. It was 
fixed in the ufual way, by a thread, to a 
bandage going round the body ; but the 
thread breaking, it immediately flipped 
in. This happened upwards of a year ago. 
The patient does not indeed experience 
much nneafinefs from it; but it had an 
evident effe^ in increafing the quantity 
of matter difcharged from the wound. 

I have met with fome cafes of wounds 

in the cheft, where folid tents have an- 

P 2 fwered 



220 Of Womds Ch. XXXVI. 

fwered the purpofe equally well with 
tubes ; and they may always be ufed 
when the parts do not contrad io ciofely 
round them as to prevent the matter 
from being freely difcharged : But when- 
ever they (lop up the pafTage fo much as 
to produce any collection of matter from 
one drefling to another, they ftiould un- 
doubtedly be laid afide, and tubes ufed 
in (lead of them. 

As tents had been ufed for a great 
length of time in almolt every wound 
which penetrated beyond the common 
teguments, Bellofte, and fome other fur- 
geons of obfervation, ventured at laft to 
lay them in a yreat meafure afide. "We 
have already had occafion to obferve, 
that this, to a certain length, was highly 
proper ; but I cannot agree with fome 
modern praftitioners who aliert, that 
tents and tubes do mifchief in every cafe, 
and that they fliould never be employed. 
Where the difcharge from a wound or 
abfcefs will continue free and uninter- 
rupted, till a cure is affeded by the parts 

filling 



Sedt. XT. in the Thorax. 221 

filling lip from the bottom, I would ne- 
ver acivile cither a tent or a tube to be 
ufed. But when we find that the exter- 
nal opening of a wound heals up long 
before the parts beneath are united, 
and that matter coUedls and burfts out 
again, as in different inftances has hap- 
pened in the courfe of my experience 
in penetrating wounds of the cheft, it 
mufl: be from want of experience only, 
or from a defire of appearing fingular, 
that we refufe to employ the only cer- 
tain method with which wc are ac- 
quainted of obviating this inconvenience, 
and of faving the patient a great deal of 
pain, trouble, and danger^ 

In extenfive wounds of tlie thorax, 
where any portion of the fternum or of 
the ribs have been removed, a portion of 
the lungs fometimes protrudes, and does 
not readily recede. When a pracffitioner 
is called foon after the accident, the pro- 
truded part fliould be replaced as quickly 
as pofTible : but when a portion of the 
lungs has been long ex poled to the air, 
P 3 apd 



Ut Of Wounds Ch. XXXVI. 

And efpecially if it has been much lace- 
rated by the accident, we Qiould, in tlie 
iirft place, fee whether or not it be in a 
ftate of mortification ; and all that is 
clearly and completely mortified fhould 
certainly be cut off before the remaining 
Ibund parts are replaced. If the inci- 
fion be confined to a part that is entirely 
gangrenons, there will be no rifl<. of in- 
ducing either hemorrhagies or any other 
fymptom ; and by removmg parts which 
are in this ifate of difeafe, we will pre- 
vent all the bad confeqiiences which 
ijiight enfue from their being returned 
into the thorax. 

S 5' Of Wounds of the Heart and large Vejfels 
connected with it, and of Wounds of the Thoracic 
Bua. 

In woimds of the heart and large 
blood-vcffels connetled with it, as thefe 
parts lie very deep, and as a found Hate of 
them is fo immediately neceflary for life, 
\\\t utmoft danger is always to be dread- 
ed- 



Se£l:. XL in the TJjorax. 223 

cd, nor is the greated exertion of pracfli- 
tloners able to lefTen It. Of fnch a ha- 
zardous nature indeed is every injury of 
this kind, that we may with propriety 
confider every wound of thefe parts as 
mortal : For although we are told in 
books, of the heart itfelf having been 
wounded without any fatal confequences 
enfuing, there is much caufe to fufpect 
that thefe accounts are founded on falla- 
cy or error. We can however conceive 
that the heart may be flightly injured 
without proving inftantly fatal ; but even 
the flighteft wound in it muft probably 
at laft end in death: For the weaknefs 
induced in this manner upon a particular 
part, will render it very liable to yield to 
the ftrong and conftant action of this 
organ. And when once an aneurifnj is 
formed in it, it will be apt to proceed 
with rapidity to a fatal termination. 

The moft probable method of prevent- 
ing this, or at leaft of delaying it, is to 
lefTen the adtion of the heart by copious 
blood-letting, by low diet, keeping the 
P 4 bowels 



S24 Of Wounds Ch. XXXVL 

bowels moderately open, and avoiding 
every kind of fatigue : If in fuch circum- 
ftances it is poiFible to fave a patient, 
thefe v/ill be the moR certain means of 
doing it ; at any rate they will tend to 
prolong life, which in fbme cafes is of fo 
much moment, that a few days or even a 
few hours may be of the utmofl: import- 
ance. 

The fame obfervations are applicable 
to wounds in the large blood- vefTels about 
the heart. They are to be conlidered as 
of equal importance and danger, and to 
be treated by the fame means with 
wounds of the heart itfelf. 

There is ftill another organ of Im- 
portance feated in the cheft, which it is 
proper to mention here, viz. the thoracic 
dud ; for although wounds in this canal 
will in mod initances terminate in death, 
yet fome advantage may, in particular 
circumilances, be derived from an atten- 
tive treatment of them. The thoracic 
duel, after leaving the receptaculum 
f hyli, runs along the fpine near to the 
gorta : and at the fifth or fixth vertebra 

of 



Seft. XI. in the Thorax. 225 

of the back, it pafles behind the aorta ; 
and afcending to the left fubclavian vein, 
it there empties the chyle. 

We judge of the thoracic dudl being 
wounded, from the part at which the 
wounding inftrument entered ; from the 
difcharge being either altogether white 
like chyle, or mixed with a confiderable 
proportion of it ; and from the patient 
becoming daily weaker than he ought to 
do from a wound of the fame fize in any 
other part, owing to the nutritive part 
of his food being carried off before any 
advantage is derived from it. 

With a view to prevent the diameter 
of this canal from being diftended, 
which at the fame time will tend to lef- 
fen the extent of the wound, the patient 
fliould be kept upon a cooling and very 
fpare diet : any food which he takes 
ihould not be at regular meals, but in 
fmall quantities frequently repeated ; nor 
Ihould he be permitted to take a large 
draught even of the weakeft liquor. The 
I^Qwels fliould be kept lax ; bodily exer- 
tion 



225 Of Wounds Ch. XXXVI. 

tion of every kind, and much fpeaking, 
or whatever tends to quicken refpiration, 
(hould be avoided. 



§ 6. Cy Wounds of the Diaphragm, Mediaftinum^ 
and Pericardium. 



"We judge of the Diaphragm being in- 
jured from the fituation of the wound, 
and from the nature of the attending 
fymptoms. As this mnfcle is in conflant 
adtion during refpiration, any injury 
done to it is necelTarily attended with 
difficulty in breathing; with much pain 
during infpiration, not merely in the 
wound itfelf, but over all thofe parts of 
the cheft to which the diaphragm is at- 
tached : The patient complains of pain 
over all the region of tjie ftomach ; fick- 
nef^, vomiting, and a troublefome degree 
of hickup take place; pains in the flioul- 
ders fbmetimes occur, together with 
cough, delirium, a quick hard pulie, and 
other fymptoms indicating inflamma- 
tion 



Sedt. XI. in the Thorax. 227 

tion and fever. Involuntary laughter is 
mentioned too as a fymptoni which in- 
juries done to the diaphragm fbmetimes 
produce. 

It is a common idea among pra<^tition- 
ers, that wounds in the tendinous part of 
the diaphragm will in every cafe prove 
mortal, but that injuries done to the 
mufcular parts of it do not fo readily 
prove dangerous. There is much reafon, 
however, to believe, that few wounds in 
the diaphragm are ever cured, whether 
they be fituated in the tendinous or muf- 
cular parts of it ; nor is it evident from 
obfervation, that there is more danger to 
be dreaded in the one cafe than in the 
other. 

The fymptoms of which we have moft 
reafon to be afraid, are thofe which pro- 
ceed either from inflammation or irrita- 
tion. With a view to prevent their ac- 
cefhon, or to moderate them when they 
have already appeared, blood-letting is to 
be chiefly depended on ; together with 
gentle laxatives ; large dofes of opiates 

con- 



22a Of Wounds Ch. XXXVI. 

conjoined with mufk ; warm fomenta- 
tions over the abdomen and thorax; 
quietnefs ; and low diet. 

By thefe means ftridlly purfued, a pa- 
tient, in fuch circumftances, will have 
perhaps a better chance of doing well 
than by any other mode of treatment ; 
but his recovery will by no means be 
certain. A ftridl antiphlogiflic courfe, 
and large dofes of opium, may probably 
obviate all the primary fymptonis. But 
however fmall a wound may at firfl: be 
in the diaphragm, the confiant adion 
and tendon of tbis mufcle will be apt to 
render it daily wider ; and we know from 
various hiilories of wounds in this part, 
that they feldom arrive at any magni- 
tude, without admitting a portion of the 
ftomach, of the colon, or fome other part 
of the bowels, to pals from the abdomen 
into the thorax ; by which the moft 
violent pain is produced, together with 
fome of the other fymptoms which ufually 
accompany a ftrangul-ated gut in cafes of 

her- 



Se<a. XL in the Thorax. 229 

hernia: In fuch circnmftances, a (Iran- 
o-ulated gnt is much more dangerous 
than a hernia in its more ordinary form ; 
for even although we (hould be able to 
remove the (Iridlure, by making an in- 
cifion into the cavity of the abdomen, as 
the pafTage into the thorax would ftill re- 
main pervious, a return of the ftrangula- 
tion might very foon be expelled. 

Wounds in. the mediaftinum require no 
peculiarity of treatment. 1 he circum- 
ftances which we have moll caufe to dread 
are, a lodgement of blood in one or both 
cavities of the cheft, inflammation and 
fuppuration, with its ufual conlequenccs. 
But the obfervations we have already 
made, refpecfting the management of pe- 
netrating wounds in other parts of the 
chefl:, apply with equal propriety to thefe; 
fo that we need not at prefent enlarge 
upon them. 

Nor is it neceflary to enter minutely 
on the confideration of wounds in the 
pericardium. As this bag contains a 
fluid which we fuppofe to be necefl 

fary 



230 Of Wounds Ch. XXXVI. 

fary for the eafy motion of the heart, 
wounds in ic may prove dangerous, 
from their tendency to prevent this Huid 
from being collerted, as well as from 
their allowing it to i'pread through the 
cavity of the cheft. It appears, how- 
ever, from various ohfervations, that 
wounds in it do not prove fo hazardous 
as might at firfl be expelled. They re- 
quire the fame general method of treat- 
ment with penetrating wounds of the 
thorax, which we have already conli- 
dered. 

In every variety of penetrating wounds 
of the thorax, where the cure is not ac- 
compliihed without the formation of 
matter, they are apt to heal flowly ; and 
in fome cafes, efpecially where abfcefTes 
have formed, a ftillicidium of matter 
>vill continue for many years, nay, in 
fome cafes, for life, notwithftanding all 
our endeavours to prevent it. As this is 
an inconveniency which patients are at 
all times anxious to be free from, pratfti- 
tioners become necelFarily much intereft- 
• ed 



Seft. XI. in the Thorax. 231 

cd in the method of treating it : and, 
with a view to leflen the difcharge, and 
even to heal the fore through its whole 
extent, aflrint^ent, and what are ufually 
termed Vuhicrary IiijeOions, have been 
advifed. But although I have known 
them frequently employed even by fur- 
geons of reputation, and under the bed 
and moft cautious management, I have 
feldom feen them ufed without fome mif- 
chief accruing from them ; and I do not 
recoiled: a fingle inftance of their being 
produdiive of any advantage. They are 
apt to irritate and inflame the lungs and 
contiguous parts ; and, inftead of heal- 
ing the fore or abfcefs, they are apt to 
extend it, by tearing open the furround- 
ing cellular fubflance. 

For this reafon, in wounds pene- 
trating the thorax, I do not hefitate 
to fay, that injetlions fhoiild be laid en- 
tirely afide : and, however difagreeable 
a tedious difcharge in this fituation may 
prove, that we fhould truft. entirely to 
the means we have already advifed for 

pre- 



232 Of Wounds Ch. XXXVI. « 

preventing the matter from lodging, 
by preferving as free and depending an 
opening as the nature of the cafe will 
admit. •* 



SECTION XII. 

Of Wounds In the Abdomen. 

§ I. Anatomical Defcription of the Abdomen 
and Parts contained in it. 

THE Abdomen, or lower belly, is the 
largefl: cavity in the body ; above, 
it is bounded by the diaphragm, which 
divides it from the thorax ; behind, 
it is fupported by the vertebrae; the 
upper part of both fides is covered by 
the inferior ribs ; the reft of it is all 
bounded by the abdominal mufcles, ex- 
cepting the moft depending part of it, 
which terminates in the pelvis ; from the 
contents of which it is only feparated by 

the 



Sed. XII. in the Abdomen. ^ 233 

the pEcritoneum ; a firm extenfive mem- 
brane, which not only lines all the cavi- 
ty, but affords a coat to all the vifcera 
containid within it, being refleded in a 
very fingular manner over them, 

Anatomifls divide this cavity into dif- 
ferent regions. The middle and upper 
part oi it, reaching from the xiphoid car- 
tilage to within a fmall fpace of the um- 
bilicus, is termed the Epigaflrium; the 
hypochondria are the fpaces on each fide 
of this ; the umbilical region extends 
from three inches or fo above the navel, 
to the fame dillance beneath it ; and all 
the parts between this and the pubes are 
termed the Hvpogaflric Region. 

In the treatment of wounds in the ab- 
domen, a minute acquaintance with the 
parts contained in it, and of their rela- 
tive fituations with refpect to each other, 
and to the divifions or regions which we 
have jufl defcribed, is a point of the ut- 
mort importance. We fhall here give a 
general defcripcion of the different vif-; 

Vol. V. Q^ cera 3 



234 Of Y/omds Ch. XXXVI. 

cera : a more particular knowledge of 
them is bell; acquired from difleclion. 

The parts contained in the abdomen 
are, the flomach and inteflines ;. the me- 
fentery, omentum, liver, gall-bladder,, 
and du(5ls ; pancreas, receptaculum chyli, 
fpleen, kidneys, ureters, and upper part 
of the urinary bladder ; the aorta, vena- 
cava, and other large blood-veflels and 
nerves. 

The flomach is a large membranous 
bag, placed in the upper part of the ab- 
domen, immediately below the dia- 
phragm : It ftretches from the left hypo- 
chondrium, where the moft capacious 
end of it is feated, obliquely acrofs the 
epigaArium, and terminates before it 
reaches the right hypochondrium. The 
ftomach has two openings ; one termed 
the Superior Orifice or Cardia, where the 
oefophagus terminates ; and the other the 
Pylorus, or Inferior Orifice, where the 
duodenum, the firft of the fmall intef- 
tines, begins. The cardia lies nearly 
©ppofice to the eleventh veitebra of the 

back^ 



Sedl. XII. in the Abdomen, 235 

back, the large extremity of the ftomach 
ftretching confiderably to the left j and 
the pylorus lies fomewhat lower, and 
nearly two inches to the right of the ver- 
tebrae. It is proper, however, to obferve, 
that the ficuatioii of the ftomach and of 
thefe two openings is confiderably af- 
fected by the quantity of food contained 
in it : So that a wound of the ftomach, 
when it is full, may be dire(5lly oppofite 
to an external wound in the teguments, 
and yet be feveral inches lower when ic 
is empty. 

The inteftines commence, as we have 
juft obferved, at the pylorus, and are con- 
tinued by many turnings or convolutions 
to the anus. This canal is in different 
parts of it diftinguifhed by different 
names : The upper part of the canal is 
termed the Small Inteftines ; and the tm* 
der part of it the, Larger, from the dia- 
meter of the tube being larger in the one 
than in the other. 

Even different parts of chefe great di- 
0^2 vifions 



22,6 Of Wounds Ch. XXXVI. 

vifions of the inteflines have received 
different names : The npper part of the 
fmall guts, extending about a foot in 
length from the pylorus, is termed the 
Duodenum : the next portion of the ca- 
nal, from being commonly found empty, 
is termed the Jejunum. This, in an a- 
duk of full growth, is fuppofed in ge- 
neral to be about four feet and a half 
in length : it is chiefly fituated in 
the umbilical region. All the under 
part of the fmaller inteftines is diftin- 
guiflied by the name of Ileum, from its 
lying almoft: entirely within the cavity 
formed by the offa ilea on oppofite fides 
of the abdomen. After making feveral 
convolutions from one fide to another, it 
at laft terminates in the csecum, the firft 
of the great inteflines fituated under the 
right kidney. From the csecum, which 
is a round fliort fac with a fmall vermi- 
form procefs, the colon originates : This 
is the largeft of all the inteflines ; and as 
it occupies a confiderable part of the ab- 
dominal cavity, the courfe of it merits 

par- 



Se6t. XII. in the Abdomen. 237 

particular attention. After leaving the 
right kidney, to which it is attached, ic 
riles and paflcs under the liver, lb as to 
be in contadl with the gall-bladder, by - 
which it is tinged of a deep yellow : 
From this it is continued in the form of 
an arch over the duodenum to the un- 
der part of the (lomach ; and paffing in- 
to the left hypochondrium, it is there at- 
tached to the fpleen and to the left kid- 
ney. This curvature is termed the 
Great Arch of the Colon. It now runs 
downward and backward ; and again 
turning up, fo as to form the figure of S, 
it terminates at the top of the os facrum 
in the laft of the great guts, termed the 
Reftum, from its running nearly in a 
ftralght line till it terminates in the 
anus. 

The inteftines being very pliable, and of 
a great length, they have neceflarily much 
freedom of motion ; but as they would 
be apt to be entangled in each other. 
Nature has provided a thin membranous 
web, termed the Mefentery, which run- 
Ct 3 i^i"S" 



23$ Of Wounds Ch. XXXVI. 

ning along the courfe of the inteftinal 
tube, ferves to conne^^ it with fufficient 
firmnels to the vertebise. The mefcn- 
tery is evidently a prodiiftion of the pe- 
ritonaeum : in its duplicature there are 
a number of fmall glands, which often 
become fo enlarged by difeafe as to be 
felt outwardly through the abdominal 
mufcles ; and it ferves as a fupport to 
the la61:eals, blood- velfels, and nerves of 
the inteftines. The omentum is a fine 
thin membrane, which comes into view 
on laying open the mufcles of the abdo- 
men and the peritoneum. In general, it 
does not pafs beneath the umbificus: but 
in corpulent people, when it is much fill- 
ed with fat, it fometimes defcends to the 
very bottom of the' belly; and in cafes 
of hernia, it is frequently met with in 
the fcrotum. 

This membrane is evidently intended 
as a protetTion to the bowels; to afford 
them an additional warmth ; and proba- 
bly by the fat which it contains to lubri- 
cate their external furfaces, fo as to ad-* 



SeQ:. XII. in the Abdomen. 239 

niit of their playing with more freedom 
on each other. 

The liver is a large glandular body, 
fltuated on the right fide immediately 
under the diaphragm : It is divided into 
two lobes ; one termed the Great and 
the other the Small Lobe. The great 
lobe lies in the right hypochondrium, 
which it fills almoft entirely : it refls on 
the right kidney, and covers a portion of 
the great arch of the colon: a confider- 
able part of the fmall lobe lies in the epi- 
gattrium ; the refl: of it paiFes over the 
flomach towards the left hypochon- 
drium. 

The liver is of a very irregular figure ; 
its outer fiirface is arched, correfponding 
to the figure and fize of the arch of the 
diaphragm. On the other fide, it is in 
fome parts flat, and in others concave, 
according to the figure of the parts with 
which it is in contatft. It is of a confi- 
derable fize and thickncfs on the ri^ht 
^de ; but towards the left its thicknefs 
a 4 de. 



240 , Of Wounds Ch. XXX VT. 

decreafes fo, that at lad it terminates in 
a thin edge. 

1 he liver is kept in its lituation by 
feveral ligaments attached to liie dia- 
phragm and contiguous parts. 

The gall-biadder is a pyriform bag, 
feated in the concave llde of the liver. 
The bile, after being fecreted by the li- 
ver, is lodged in this. bag, from whence 
it is conveyed into the inteliincs thro' 
the dudns choledochus, which enters the 
duodenum by piercing its coats in an ob- 
litine direction, about five inches below 
the pylorus. 

The pancreas is a conglomerate gland, 
lying in a tranfverle direftion be ween 
the liver and fpleen, immediately nnder 
the flomach. The liquor fecreted by 
this gland is carried into the duodenum 
by a iinall duOi, which in fome cafes termi- 
nates in the gut iifcif, and in others near to 
the extremity of the du(Slus choledochus. 

The recepraculum chyli is a Imall 
membranous bag, through which the 
phyle pafles froni the inteflines to the 

left 



Sed. XII. in the Abdomen. 241 

left fubclavian velti by means of the tho- 
racic du(fi:. Tliis bag, or fac, lies upon 
the firlt vertebra of the loins, a little to 
the right of the aorta. 

The I'pleen is a large fpongy body, 
feated in th^ left hypochondrium, be- 
tween the ftomach and the falfe ribs, 
under the diaphragm, and immediatel/ 
above and contiguous to the left kid- 
ney. ' 

In Chap. XL Secfi:. II. we gave a d"*> 
fcription of the kidneys, ureters, and 
bladder ; fo that at prefent we need not 
enter upon it. But, befides the feve- 
ral vlfcera which we have mentioned, 
the aorta, vena-cava, and the large blood- 
veflels and nerves which fupply the 
bowels, lie all within the abdominal ca- 
vity. 

We may didinguifli wounds of the ab- 
domen in the fame manner as we have 
done wounds of the thorax. They may 
either be confined to the common tegu- 
ments and mufcles, or they may pene- 
trate the cavity ; or a penetrating wound 

may 



242 Of Wounds Ch. XXXVL 

may be complicated with wounds of one 
or more of the vifcera. 



§ 2. Of Wounds of the Teguments and Mufcles 
of the Abdomen. 

In one point of view, wonnds of the 
teguments and mufcles of the abdomen 
do not merit more attention than fimilar 
injuries in other parts of the body ; but 
they become highly important from 
the contiguity of the abdominal vifcera, 
and from die danger of thefe being ul- 
timately injured by the negle<5l or mif- 
mana2:ement of the exter. al wound. 

Our firfl: objecf is to difcover, Whether 
a wound has penetrated the abdomen or 
not ; and whether any of the vifcera are 
injured. When the wound is extenfive, 
and any portion of the vifcera protrudes, 
t\\c nature of the injury is evident ; but 
in finaller wounds where no part of the 
bowels appear, it is often difficult to 
judge whether they penetrate the abdo- 
men or not. In general, however, this 

point 



Sc£t» XII. in the Abdomen. 243 

pclnt may be determined by attention to 
the following circumftances : by a pro- 
per examination with the fingers or probe, 
after putting the patient as nearly as 
poflible into the pofture in which he re- 
ceived the wound : by the form and fize 
of the inflrument, the depth to which it 
run,, and the dircdion it appeared to 
take ; by the quantity of blood difchar- 
ged at the wound being confiderable or 
not ; by the ftate of the pulfe and other 
attending fymptoms ; and by the dif- 
charge of fseces, bile, or any other of the 
abdominal lecretions. 

When the wound is of fuch a fize as to 
admit the finger, we may always deter- 
mine with certainty whether it reaches 
the cavity of the abdomen or not ; as 
in this cafe the finger will come into 
contact with the vifcera : but probes 
lliould be ufed with much caution ; and 
unlefs the inflrument pafles eafily in, 
without force, in a dired: line, and to 
fuch a depth as to convince us that it has 
reached the cavity, little or no depend- 
ence 



244 Of Wounds Ch. XXXVI. 

ence fliould be placed upon it : For the 
parts here are fo fot'c, and of fuch a yield- 
ing nature, that a probe with very little 
force will pafs among them almofl: in 
every diredion to a confiderable depth. 
It is fcarcely necefTary to oblerve, that it 
is particularly proper, in every inquiry 
of this kind, to put the patient as nearly 
as poflibie into that porture in which he 
received the wound. And the loofe tex- 
ture of the parts ftiould prevent us from 
ufing injeOions, as is frequently done 
with a view to determine this queftion. 
In wounds of the thorax, where the parts 
are firmer and more intimately connec- 
ted, inje(5lions may be ufed for this pur- 
pofe more fafely ; but in the abdomen 
they are apt to fpread among the muf- 
cles and cellular fubftance, by which the 
teft is rendered uncertain, at the fame 
time that mifchief is apt to enfue from 
the pain and inflammation which are in- 
duced. 

The depth to which the inflrument 
has paflTed, or the dirediion which it 
took, cannot be often afcertained ; but 

when 



Seft. XII. - in the Abdomen. 245 

when this informauon can be obtained, 
it will aflifl us in judging of the nature 
of the wound. By comparing the fize of 
the external opening with the fize of the 
inflrument, we may be led to determine 
the depth to which it has pafled. 

When the quantity of blood difchar- 
ged from a wound in tlie abdomen is 
confiderable, we may conclude almofl 
with certainty, that Ibme of the large 
internal vefTels have been injured j for 
excepting the epigaftric artery, which 
runs in the anterior part of the abdomen 
in the courfe of the redus mufcle, none 
of the teguments or mufcles of thefe 
parts have arteries of fuch a fize as to 
afi'ord much blood. It is proper, how- 
ever, to obferve, that even the largeft ar- 
tery in the abdomen may be wounded 
without any blood being difcharged ex- 
ternally ; for if the outward opening be 
not confiderable, and efpecially if the 
wound runs in an oblique diredlion, the 
blood, inftead of being evacuated at the 
opening, will be extravafated into the 

cavity 



246 Of Wounds Ch. XXXVI. 

cavity of the belly, where large quan- 
tities of it may be colledled, even with- 
out any remarkable degree of tenfion ta- 
king place. 

In fuch cafes, however, we are foon 
led to fufpet5l what has happened by the 
fymptoms which enfue. The patient 
complains of debility and faintnefs ; his 
pulfe becomes low ; he is feized with 
cold fweats ; and if the difcharge of 
blood be not flopped, every other fymp- 
tom of approaching death foon make 
their appearance. 

It fometimes happens again that 
we are at once rendered certain that a 
wound has penetrated the cavity of the 
abdomen, by the difcharge of faeces ; of 
bile; of the pancreatic juice, or even of 
chyle : and in fome cafes, the fame cer- 
tainty is obtained by large quantities of 
blood being thrown up from the fto- 
mach, or difcharged by the redlum. U- 
rine may be difcharged by a wound 
which does not penetrate the belly ; 

for the kidneys and ureters may with 

pro- 



Seft. XII. in the Abdomen. 247 

propriety be faid to lie behind the peri- 
tonaeum, as well as a confiderable por- 
tion of the bladder; but they are in ge- 
neral to be treated in the fame manner ' 
with penetrating wounds in the abdomen. 

When, again, none of thefe fymptoms 
take place ; when neither the finger nor 
probe can be eafily introduced ; when 
there is no difcharge from the wound 
that leads to fufpedt the vifcera to be 
wounded j when the pulfe remains na- 
tural ; and when the pain is moderate; 
there will be much caufe to hope that it 
has not palTed to a greater depth than the 
common teguments or mufcles. 

In the treatment of thefe wounds, we 
are to be entirely diredled by the depth 
to which they penetrate, and by the fymp- 
toms which take place. 

When it is difcovered that a wound 
in the abdomen does not run deeper than 
the common teguments or mufcles, if 
none of thefe parts have been removed, 
we will feldom meet with any fymptoms 
of importance, at leaft where the habit 

of 



248 Of Wounds Ch. XXXVr. 

of body is good, except where they are 
the confequence of negled or mifma- 
nagement. Our views here {liould be 
nearly the fame with what we have ad- 
vifed in wounds of the thorax. The 
principal objedt is to prevent inflamma- 
tion and the lodgement of matter, which 
is done by blood-letting ;" a low diet; 
the nfe of laxatives ; reft of the body ; and 
proper attention to the wound. But for 
a more particular detail of the proper 
treatment of fuch a wound, we ihall re- 
fer to the lad fedtion. 

It is proper, however, to remark, that 
wounds in the boundaries of the abdo- 
men, in one circumftance, differ mate- 
rially from fimilar injuries of the thorax. 
As the mufcles and other foft parts of 
the cheft are every where fupported by 
bone, the lungs and other vifcera con- 
tained in the breaft do not readily pufli 
out at the wound : but as the coverings 
of the abdomen are of a foft yielding 
nature, having anteriorly no bone to 
fupport them, and many of the contain- 
ed 



ScQ.. XII. in the Abdomen,. 249 

ed parts having no very clofe attach- 
ments, they are apt to pulh forward and 
protrude wherever any unufiial degree of 
weaknefs occurs. In all wounds there- 
fore of the abdomen, even where they 
do not penetrate, fome caution is ne- 
cefTary from this confideration alone ; 
and more efpecially fo when any portion 
of the teguments or mufcles has been 
removed. The patient fhould be kept as 
much as poflTible in a horizontal pofture 
during the whole cure ; and when he at- 
tempts to fit or walk, the weakened parts 
fhould be fupported by a proper com- 
prcfs, and a firm, fomewhat elaftic, ban- 
dage of flannel pafled two or three times' 
round the body; a caution which ought 
to be perfifled in for a confiderable time 
after the cure of the fore is completed. 
By want of attention to this point, very 
troublefome cafes of hernias have occur- 
red which vv'ith eafe might have been 
]i evented. 



Vol. V. R 



256 df Wound} Ch. XXXVX; 



§ 3. 0/" Wounds which penetrate the Cavity of the 
Abdomen, but which do not injure any of the 
contained parts. 



Although an Inftrument may have 
penetrated to a confiderable depth, we 
have much realbn to hope that none of 
the vifcera are wounded, as long as the 
abdomen remains free from much pain 
and tenfion, the pulfe foft, and the fkin 
of a 'natural heat : But even in this ftate 
of fuch a wound, we are not to conclude 
that there is no hazjird ; for it often 
happens, that wounds in thefe parts, 
which at firft exhibit no appearance of 
danger, at iaft terminate fatally. 

It is proper, however, to obferve, that 
this may often be traced as an efFe<fi: of 
improper management, and that pradi- 
tioners have it frequently in their power 
to prevent it : For although fome in- 

ftances 



Se6l. XII. in the Abdomen, 251 

ftances will occur of wounds of this kind 
ending fatally, where no fymptoms ap- 
peared of the vifcera being wounded, 
and where after death no immediate in- 
jury was found to be done to them, yet 
this will not ufually happenin fuch wounds 
that are properly treated from the firfl:. 

The danger which occurs here arifes 
chiefly from two caufes ; from the accefs 
of air to the cavity of the abdomen, by 
wl)ich the different vifcera are apt to 
become inflamed ; and from the fubfe- 
quent formation of matter, which, not 
finding an opening, will necefllarily col- 
left within the peritonaeum. 

In every wound therefore of this kind, 
after fecuring any blood-vefl^l of the te- 
guments or mufcles that may have been 
cut, and which we fliould always do by 
ligature immediately on its being difco- 
vered, our next objed fliould be to pre- 
vent, with as much certainty as poflible, 
all manner of accefs to the air. In fmall 
wounds of thefe parts, this will be dpne 
R 2 with 



252 Of Wounds Ch. XXXVI. 

with mcft eafe and certainty merely by 
the lips of the cut being drawn together, 
and fecured with feveral plies of adhefive 
plafter : and as a farther fecurity, a com- 
prefs and flannel roller, fuch as we have 
mentioned above, may be put over the 
whole : The fame precautions with re- 
fpe€l to blood-letting ; a ftri6l antiphlo- 
giftic regimen, and reft of body, which 
we recommended in more fuperficial 
wounds cf the abdomen, fhould be here 
carefully obferved where the danger is 
more confiderable. 

By this management thefe wounds, 
when fmall, will often heal by the firft 
intention ; but when they continue open 
for fome time, they ihoyld be drefled as 
feldom as poffible, and the drefling fliould 
be renewed with as much expedition as 
the nature of the cafe will admit, fo that 
the unneceffary admifllon of air may be 
avoided as much as poffible. 

It will fomctim>es happen, however, 
even that the moft exafl attention will 

not 



Se£t. XII. in the Abdomen. 253 

not prevent the acoeffion of bad fyrnp- 
toins : At firfl: they will moit readily be 
of the inflammatory kind, which will be 
removed by farther evacuations of blood, 
and attention to the other circumftances 
we have enumerated ; or they will prove 
fatal, by ending in mortification ; or 
they may terminate, as we have mention- 
ed above, in the formation of matter. 
It is this lafl occurrence which we hav^ 
now to a.dvert to. 

In fuch circumflances, we would ad- 
vife an openitig to be made in any other 
part of the body immediately for the <lif- 
charge of the matter: But in thefe dif- 
pofitions in the abdomen, we can never 
difcover with certainty, whether any 
colledlion has taken place or not, till it 
has continued for a confiderable time : 
for the matter here lies in deep, that a 
fmall quantity cannot be diftinguifhed ; 
nor v/ould it be proper for the difcharge 
of a fmall quantity of matter to incur 
that danger which always attends the 
free admiffion of air to the abdomen j 
R 3 and 



254 ' Of Wounds Ch. XXXVI. 

and in fmall colledlions this could not 
be avoided, as there would be a neceffity 
of opening them in a flow gradual man- 
ner with a fcalpel, as in fuch cafes the 
trocar could not be plunged in without 
much rifk of hurting the vifcera. In- 
ftead of fuch an attempt, therefore, we 
Ihould do nothing a^ long as the quanti- 
ty of matter continues moderate, and 
while no bad fymptoms have yet taken 
place. Indeed this is a good general rule 
in all wounds of the abdomen, never to 
inquire with much anxiety Cither for col- 
led^ions of matter, or for fuch parts ss 
from the nature of the wound there 
might be caufe to fufped fliould be inju- 
red, till the appearance of fymptoms ren- 
ders it probable that the one or the other 
has taken place : for by much handling 
we often do mifchief; while frequently 
no danger enfues from wounds which ar 
firft were attended with very alarming 
fynlptoms. Nay we know, that in dif- 
ferent inftances a perfon has been run 
through the body with a ifmall fword 

with-, 



Sedl. XII. in the Abdomen. 255 

■without any of the vifcera being injured, 
and the patient has done well without 
any bad fymptom taking place. And we 
likewife know, that violent inflamma- 
tion will Ibmetimes terminate favourably 
without the formation of matter ; and 
even when matter is formed, that it will 
fometimes be carried off by abforption, 
fo as to leave no veftige of its having 
ever exifted. It is the a<Elual prefence 
therefore of bad fymptoms produced by 
fuch colledions of matter, or the quan- 
tity of matter becoming fo confiderable 
as to prove inconvenient to the patient, 
that fhould indicate the propriety of ma- 
king an opening for difcharging it : But 
as foon as we find this to be the cafe, we 
fhould not hefitate ; and whenever there 
is fuch a quantity collecfled as to admit 
of the trocar being employed, we may 
drmv it off with eafe and fafety : For by 
inferting the inftrument in an oblique 
diredion, no air will be admitted ; by 
which the only rifk. which attends this o- 
peration will be avoided. I have been the 
R 4 more 



65<5 Of Wounds Ch. XXXVI. 

more partic^ilar upon this fubjetfl, from 
having obferved two cafes of this kind 
terminate fatally where there was not 
previoufly any appearance of danger. — 
As it was evident in both cafes that mat- 
ter was colletled, it was determined to 
difcharge it ; and, as it was fuppofed to 
be feated either in a particular cyft, or 
in the fnbftance of the mufcles, and not 
in the cavity of the abdomen, it was done 
by making a fmall opening into it with 
a fcalpel. But in both, the mofl; violent 
fymptoms of inflammation occurred in 
the courfe of the firft two days ; and the 
patients foon died. And I conclude that 
it was by the free admiffion of air to the 
cavity of the abdomen that thefe fymp- 
toms were induced ; for after death the 
matter was found to be lodged in that 
cavity ; and I have fince that time, in 
two fimilar cafes, drawn large quantities 
of purulent matter off with a trocar, 
where it was evidently feated in the ab- 
domen, without any bad confequences 
enfuing. 

In 



Se£l. XII. in the Abdomen. 257 

In drawing off matter from the abdo- 
men, the fame precautions are neceflary 
in doing it that are now fo univcrfally 
admitted in difcharging ferum by the 
ufual operation of the paracentefis. But 
as we gave a particular account of this 
in Volume II. Chapter XXI. we mult 
now refer to what was then faid upon it. 

Penetrating wounds of the abdomen 
may prove dangerous from another caule. 
Confiderable portions of the bowels are 
fometimes protruded, without any other 
injury being done to them ; and this may 
be producilive of fatal confequences. 

The mod certain method of prevent- 
ing danger in all fuch cafes, is to return 
the protruded parts as quickly into the 
belly as can be done with propriety. — - 
Almofl: every writer upon this fubje<5l 
defires us in the firfl: place to foment 
them with warm emollient deco(^ions, or 
to cover them for fome time with the 
web or omentum of fome new-killed ani- 
mal : but they do not recolie(!:l:, that du- 
ring the time loft in making thefe prepa- 
rations, 



as^ Of Wounds Ch. XXXVI. 

rations, the protruded parts will proba- 
bly fufFer more than can be gained by 
the application of them ; and that the 
mofl- natural, as well as the moft proper 
fomentation for them, is the heat and 
moifture of the patient's belly. In re- 
commending thefe applications, it is faid, 
that they not only remove the dry parch- 
ed ftate of the parts which expofure to 
the air is apt to induce; but by means 
of them we are enabled to judge with 
more certainty whether or not they are 
in a flate that admits of their being re- 
turned with fafety : for it is alledged, 
even by fome writers of reputation, that 
parts which are apparently in a ftate of 
incipient gangrene, and which otherwife 
we might be afraid of pufhing into the 
abdomen, may, by a proper ufe of thefe 
fomentations, be fo far recovered as to 
render it highly proper to return them. 

But although this opinion has been 
very generally received, and the prac- 
tice followed which it inculcates, it ap- 
, pears to me to be fo fraught with im- 
propriety 



Sed. XII. in the Abdomen. 259 

propriety and danger, that I cannot pafs 
it over wichoat mentioning in the ftrong- 
e(l manner the idea I entertain of it.— • 
Much mifchief may be produced by it, 
and I fee no advantage that can accrue 
from it. 

By many it is faid, that no part of 
the inteftines fhould be returned into 
the abdomen that have once acquired 
any tendency tp gangrene, on account 
of the rifle of fhe fsces bijrfting into 
the belly, by whic^i the patient would 
neceflarily die. Wherevei' there is a 
certainty of" fuch an occurrence, by the 
parts being adually in a flare of gan- 
grene, to return them to the abdomen 
■would no doubt be highly improper, as 
it would be depriving the patient of the 
only chance which he can have of a re- 
covery, that of fecuring the ends of the 
found parts of the gut at the mouth 
of the wound, by which there may be 
fome pofTibility of their uniting after- 
wards, as has happened in different in- 
ftances ; and by which he will at leafl 

be 



2(?o . Of Wounds Ch. XXXVI. 

be certain of having at all times a free 
difcharge for the fa;ces. Bat although 
in this fituation the pradice we allude to 
is to be confidered as highly proper, yet 
when gangrene has not adually taken 
place, as there v^ill ftill be fome caufe to 
hope that the natural heat of the belly 
may prevent it, the parts (hould be'^nftant- 
ly returned. 

When parts protruded from the abdo- 
men are covered with fand, duft, or any 
other extraneous matter, it will no doubt 
be proper to clear them of it before 
they are replaced ; and with this view, 
bathing them in warm milk, or in milk 
and water, may anfwer better than any 
other method. But this is perhaps the 
only caufe that can render the pradice 
necelTary. 

Some addrefs is neceiTary in returning 
any part of the inteftines which have 
been protruded in the eafieft manner. 
The patient fhould be- put into that po- 
flure which will moft eflfedlually relax 
the parts in which the wound is feated, 

. with 



Seft. XII. in the Jbdomen. 261 

with his head and cheft fomevvhat lower 
than the abdomen and buttocks, Co that 
the weight of the bowels may have fome 
effedi in dragging in the protruded parts. 
When in this fituation, the furgeon ha- 
ving his fingers dipped in warm oil, or 
covered with foft oiled linen, fliould en- 
deavour to replace the parts by begin- 
ning his prefTure at one of the ends of 
the gut, and continuing it along the 
doubling or curvature to the other. In 
this manner any portion of the bowels 
will be ealily replaced without any far- 
ther enlargement of the wound, when 
the opening is not very fniall: And when 
any part of the omentum, or any others 
of the vifccra, are protruded, there will 
be ftill lefs difficulty in returning them. 
But confiderable parts of the inteftines 
are frequently pullied out at fuch fmall 
pundlures, that they cannot be returned 
but with much more prefllire thanftiould 
ever be applied to them. In this cafe, 
our object will be more eafily accom- 
plKhcd, and with lefs hazard co the pa-. 

tient, 



^62 Of Woundi Ch. XXXVL 

tient, by enlarging the opening, than by 
^ the application of fo much force as is ge- 
nerally required in pufliing any confider- 
able portion of gut through a fmall aper- 
ture. Some dexterity, however, is ne- 
cefTary in enlarging an opening in this 
ficuation. When the aperture is of fuch 
a lize as to admit the finger of the fur- 
geon, it may be done with eafe and fafe- 
ty : but in fome cafes it is fo complete- 
ly filled with the pares which pafs thro' 
it, that this is impracticable. In this fi- 
tuation, we are advifed by authors to 
infert a director between the bo,wels and 
the parts to be divided, and to enlarge 
the opening by cutting upon it either 
with a fcalpei or bifloury. This, how- 
ever, mufl: be attended with much ha- 
zard ; for we can never dirtinguifh with 
certainty whether feme plies of the bow- 
els be elevated by the director or not, as 
this will ibmetimes happen notwithftand- 
ing all our care to prevent it. Inflcad of 
following this method, I have in dif- 
ferent cafes enlarged the opening, by 

making 



Se6l. Xtl. in the Abdothetu i^i^ 

making an incliion through the integu- 
ments and mufcles with a Icalpel, in the 
fame gradual manner that we operate in 
cafes of hernia ; taking care, as foon as 
the peritonaeum is laid bare, to introduce 
the end of a probe-pointed biftoury be- 
tween it and the cut, and dividing it as 
far as may be neceflary, which now may 
be done with entire fafety. If in this 
manner the opening be enlarged fo as to 
receive the point of the finger, it may 
afterwards be increafed at pleafure, by 
inferting the finger fo as to a6t as a con- 
dudlor for a biftoury or fcalpel : But till 
it can be done in this way, no cutting 
inftrument fliould ever be palTed into the 
abdomen ; for although much ingenui- 
ty has been ftiown in the invention of 
inftruments with wings to protedl the 
bowels in this part of the operation, yec 
none of them anfwer any other purpofe 
than to render the bufinefs more com- 
plex. 

In enlarging a wound in this fituation, 
it fhould be done as much as poffible in 

the 



2^4 Of Wounds Ch. XXXVI. 

the diredllon of the mufcular fibres of 
the parts; and, for an obvious reafon, 
the incifion iliould commence at the bot- 
tom of the wound, and be carried down- 
wards, and not ;it the top. 

We may thus enlarge the opening to 
any necefTary extent, always taking care 
not to make it larger than the nature of 
the cafe may require. And this being 
accomplifhed, the protruded parts fhould 
be replaced with as much expedition as 
poHible in the manner we have advifed. 
In returning bowels to the abdomen, it 
has fometimes happened, through confu- 
fion or miflake in the operator, that they 
have been puflied in between the layers 
of the abdominal niufcles. This fliould 
be guarded againfl with the utmoft at- 
tention ; for when left in this fituation, 
the patient will be nearly in the fame 
danger as at firfl:. Indeed this will be 
the cafe if they be not placed altogether 
within the peritoneum* 

The accident we allude to may hap- 
pen in any part of the belly, when a 
furgeon is not fufficiently accurate and 

attentive : 



Se£t. XII. in the Abdomen. 265] 

attentive : but it is mofi likely to occur 
in wounds that pafs through either of 
the redli mufcles, owing to the flieaths 
of thefe mufcles being particularly loofe 
and flaccid ; and it will more readily 
happen in corpulent people than in o- 
thers, owing to the great depth of fat 
and cellular fubftance, which, in fubjedls 
of this defcription, lie above and betweea 
the different mufcles of the abdomen. 

Inrtead of enlarging the opening in 
the abdomen, it has been propofed 
to difcharge the air contained in the 
protruded portion of the bowels, by 
making holes in it with a needle, by 
which the bulk of it may be fo much 
diminifhed as to admit of its being ea- 
fily replaced at the fame opening. As 
this has been mentioned by writers 
of experience, I think it right to fpeak 
of it ; but it is chiefly with a view 
to caution the younger part of the 
profefTion againft it. Jt may indeed 
be done with more eafe to the opera- 
tor ; but this appears to be the only ar- 

VoL. V. S gumenc 



266 Of Wounds, ' Ch. XXXVI. 

gument in its favour : For although 
fome may have recovered on whom it 
has been pradlifed, yet furely the fmall- 
eft opening made into the gut mull be 
attended with much more danger than 
can probably arife from the external 
opening in the teguments and mufcles 
being fomewhat enlarged. And belides, 
in reducing protruded bowels, however 
diftended they may be with air, we may 
often render them perfecftly flaccid by 
prefling the air contained in them into 
that part which remains in the abdomen. 
And if this be cautioufly done, it may at 
all times be attempted with fafety. In- 
deed no trial fliould ever be made for the 
reduction of a portion of inteftine that 
is much inflated, till we have endeavour- 
ed in this manner to reduce the fize of 
it. 

After the bowels are replaced, our 
next objecH: is to preferve them in their 
fituation till the wound is fo firmly con- 
folidated as to prevent them from falling 
out. When the opening is fmall, this 

may 



Seel. XI I. in the Abdomen. ' 267 ' 

may be efFedlually done by laying the 
patient in a proper pofture, with his 
head and buttocks elevated ; by prevent- 
ing coftivenefs ; and by a firm roller of 
flanne) paffed feveral. times round the 
body, fo as to f'upport the injured parts 
till they are united. But in extenfive 
wounds of the abdomen, it ie found, e- 
ven when they are treated with every 
polTible attention, that it is difficult, and 
in fome cafes impoffible, to prevent the 
bowels from prolapfing by the ordinary 
dreffings and bandages. In fuch cafes, 
we are under the neceffiry of drawing 
the fides of the wound together by fu- 
tures ; an operation commonly termed 
Gaftroraphy. 

Various methods have been propofed 
for making this future ; but the common 
interrupted future, or the quilled future, 
which is merely a variety of the other, 
anfwers the purpofe better than any of 
them. Much care and attention, how- 
ever, is neceffary in paffing it, particular- 
ly in avoiding the bowels, v;hich every 
S 2 where 



268 Of Wounds Ch. XXXVi; 

where lie contiguous to the parts to be 
united. 

The furgeon being provided with a 
number of broad flat ligatures, fufRcient 
for the extent of the wound, and of a 
ftrength that will retain the parts toge- 
ther, each ligature Ihould be armed with 
two large curved needles, one towards 
each end ; and the patient being laid in 
a pofture that is mofl: eafy for himfelf, 
at the fame time that it relaxes the inju- 
red parts mod: effedtually, the furgeon 
{hould now infert the fore-finger of his 
left hand into the wound, and being fure 
that it is in conta(5l with the peritonae- 
um, without any of the bowels lying be- 
tween them, he ihould now pafs the point 
of one of the needles along his finger to 
the diflance of an inch at leaft from the 
edge of the wound ; and having fecured 
the other end of it with the thumb and 
palm of his hand, he muft now pufh it 
oiuward, fo as to make it pierce the fkin 
at a fimilar diftance from the external 
wound in the teguments. In this he 

will 



Seft. Xli. in the Abdomen. 26g 

will be mnch ailirted by prefling the 
miifcles and (kin down upon the needle 
with his right hand: and one of the 
needles being pafFed, the other mufl: in 
like manner be pndied through the op- 
pofite fide of the wound, by carrying ic 
alfo from within outward. It might in- 
deed be done by entering the needle out- 
wardly, and carrying it in upon tlie fin- 
ger : but we could not in this manner 
avoid the bowels with fuch certainty; a 
point of the utmod importance, and re- 
quiring the nicefl attention. 

The firft needles fliould be pafiTed with- 
in half an inch of the upper part of the 
opening ; and the others fliould be con- 
tinued to within an equal diftance of the 
bottom, at the dillance of three quarters 
of an inch from each other ; for as the 
retraction of parts divided in this man- 
ner is more to be dreaded than any other 
occurrence, it ought in a particular man- 
ner to be guarded againd. The liga- 
tures being all inferted, the parts fliould 
now be fupported by an affiilant ; and a 
S 3 proper 



^76 Of Wounds Ch. XXXVL 

proper knot being tied upon each of 
them, the whole extent of the wound 
{lioLild be covered with a pledgic of lint 
fpread' with any un^lnous fiibftance, for 
preventing acceis to the air. After this, 
the parts fhoiild be fupported with a roll- 
er : The patient iliould now be put to 
bed, and fhould be treated in the manner 
we have dire<!:ted above, wich blood-let- 
ting, and a low regimen, in proportion 
to the violence of the fymptoms which 
fupervcne. 

In performing this operation, I have 
faid that the ligatures fliould be conti- 
nued to within half an inch of the bot- 
tom of the wound ; which is contrary to 
the ufual pradice. In general an open- 
ing is left beneath, with a view to dif- 
charge any matter that may form in thp 
conrfe of Liit cure ; but there is no fuffi- 
cient reafon for doing fo. Inflead of 
proving ferviceable, it is probable that 
it mull often do harm, by giving tree 
flccefs to the air, which in every wound 
^i the abdomen fliould be pariicu- 
Isrly guarded againfl. The opening 

coulcj 



Sed. XII. in the Abdomen. 271 

could not be prefer ved without the a(fift- 
ance of a tent, by which much irritation 
and pain might be induced : nor would 
it ever anfwer thepurpofe of difcharging 
the matter, excepting it be accidentally 
fituated near to the under part of the ab- 
domen. I am clear, therefore, that the 
whole extent of the wound (liould be 
treated in the fame manner ; and if mat- 
ter' Qiould afterwards form, that it will 
be better to truft to its being abforbed, 
or even evacuated by the trocar in the 
manner we have already mentioned, than 
to trull to this precarious method of 
treatment. 

When any practitioner prefers what is 
ufually termed the Qiiilled Suture, the 
one we have defcribed may be eafily con- 
verted into it, by introducing each of 
the ligatures double. After all the liga- 
tures are pafTed, a fmall roll of plafler, 
or a piece of a large bougie; fliould be 
pafTed through the dilFerent loops, which 
ought all to be on one fide of the wound ; 
and a fimilar roll being placed on the 
S 4 oppofite 



972 Of Wounds Ch. XXXVI. 

oppofite fide between each of the liga- 
tures, tliey mud now be tied upon it 
with running or bow knots, of fuch a 
tightnefs as may appear to be necefTary ; 
care being taken during this part of the 
operation to have the fides of the wound 
properly fupported by an affiilant. 

If the parts are properly and equally 
drawn together, we will feklom find it 
necefl^ary to remove the ligatures tillthe 
parts are united, which they will always 
be in fix or fevendays, if they have been 
kept in dole contact, and if no unufual 
caufe has occurred to prevent it. But 
when the ligatures give much pain, and 
efpecially when the patient complains of 
much tenfion over the abdomen, the 
knots fhould always be untied and kept 
perfectly loofe, till by blood-letting, fo- 
mentations, and gentle laxatives, thefe 
fymptoms are removed, when the parts 
may be again drawn together and fecu- 
red as before. 

We have hithertobeen fuppofing that 
^he protrpded part confifts of a portion 

of 



Sett. XII. m the Abdomen. 273 

of the alimentary canal only, this being 
the part which in wounds of the abdo- 
men is moft frequently puftied out : but 
it is proper to remark, that the other 
vifcera are alfo liable to be' protruded, 
particularly the ftomach and omentum. 
This, however J does not vary the me- 
thod of treatment, which ought to be 
nearly the fame, whichever of the vifce- 
ra be puflied out. The parts fliould in 
every inftance be replaced as quickly as 
poffible, and retained in the manner we 
have alreadypointed out. 

We are now to confider the treatment 
of thofe wounds in the abdomen which 
are attended with injuries done to one 
or other of the vifcera. And in the firft 
place, wounds of the alimentary canal 
require our attention, as being moft fre- 
quent. 



§4.0/ 



274 Of Wounds Ch. XXXVI. 



§ 4. (y Wounds of the Alimentary Canal. 

In a former part of this fecftion we 
have obferved, that wounds of the in- 
teftines may be difcovered by the dif- 
charge of blood from the mouth and by 
the anus, as well as by the difcharge of 
fasces from the wound in the teguments : 
We likewife judge of this point by the 
difcharge of fetid air from the wound, 
and from the depth and diredlion in 
which the inftrumeut appeared to run. 

By attending to thefe circumftances, 
and to the fymptoms with which woimds 
in the inteflines are commonly attended, 
fuch as naufea, ficknefs, violent gripes, 
or pains through the abdomen, cold 
fwears, and faintings, we may in general 
determine with much certainty whe- 
ther they are injured or not. But un- 
lefs the wounded part be brought in- 
to view, little or no advantage is gain- 
ed by the difcovery : for while it re- 
mains 



Seft. XII. in the Abdomen. 2y$ 

mains iindifcovered, our method of 
treatment muft be nearly what we have 
recommended for wounds which mere- 
ly penetrate the cavity. Authors in- 
deed direcH: us to fearch for the wound- 
ed part of the gut : But as the danger 
from the extent of the wound, which in 
this cafe would be requifite, as well as 
from the expofure of the contents of the 
abdomen, would probably be greater 
than from allowing the wounded part to 
remain, this attempt ought never to be 
made ; the more efpecially as we know- 
that wounds in the inteftines have been 
healed, although the injured part has not 
been difcovered. 

When we find, however, that a wound 
is inflicled on a portion of protruded 
gut, we ought by no means to replace it 
till we endeavour to prevent its con- 
tents from being effufed into the cavity 
of the abdomen ; which can only be done 
by fewing up the opening. 

There are different methods propofed 
for fccuring openings of this kind. Le 

Dran 



276 Of Wounds Ch. XXXVI. 

Dran thinks that it may be done with 
mod fafety by what he terms the Looped 
Suture ; while the generality of pracH- 
tioners effeifl it by the Glover's Suture. 
The looped future is performed in the 
following manner : One end of the 
wound is to be iield by an afliftant, while 
the furgeon does the fame with the other; 
and the needles, which Qiould be round, 
ftraight, and fmall, carrying eacli of them 
a thread a foot long, mud be equal to 
the number of flitches intended to be 
made. As many of the ligatures are 
now to be paffed through both lips of 
the wound as appear to be necefTary, 
taking care that they are nearly a quar- 
ter of an inch diftant from each other. 
The threads being all pafled, and the 
needles removed, all thofe on one (\dt of 
the cut mufl be tied together with a knot 
at their ends, and thofe on the oppofite 
fide mufl: afterwards be fecured in the, 
fame manner. They are now to be join- 
ed together, and to be twifted two or 
three times round, fo as to form a kind 

of 



SeQ:. XII. in the Abdomen. 



277 



of a cord : By this means the divided 
parts of the intefline are puckered toge- 
ther, io that the ftitches, which before 
were diftant about a quarter of an inch, 
are now brought clofe to each other. 
The future being thus finiihed, an affift- 
,anc niuft hold the two ends of the twift- 
;d threads, whilft the furgeon replaces 
the inteftine in the manner we have al- 
ready diredled. The threads are to be 
fecured to the bandage, which is put 
over the dreffings ; and after remaining 
till the wound in the gut may be fuppo- 
fed to be healed, they are to be untwifl- 
ed ; and one fide of each of them being 
cut off clofe to the external wound, they 
mufl: now be drawn cautioufly and fepa- 
rately away. 

The principal obje6\ion to this method 
of ftitching thefe wounds is, that in fome 
degree it mud contradl the diameter 
of the gut, by which dangerous ob- 
ftruclions might afterwards be produ- 
ced. Inftead of it, the Glover's Suture, 
as it is termed, is commonly pradifed. 

In 



278 Of Wounds. Ch. XXXVI. 

In making this future, a fmall, fine, 
round needle (hould be ufed, armed with 
a thread of filk. The furgecn laying the 
lips of the wound exadlly together, muft 
perforate both at the fame time ; and 
carrying the needle to the fame fide at 
which it entered, he muft now make 
a fecond ftitch at a fmall diftance, per- 
haps at the eighth part of an inch from 
the firft ; and in the fame manner muft 
continue, by a proper number of ftitches, 
to draw the whole extent of the wound 
together. This being done, a fufiicient 
length of the thread is to be left out at 
the external wound, for the purpofe of 
drawing it away when we fuppofe the 
wound in the gut may be united- 

Even this method of treatment, how- 
ever, muft evidently tend to leflen the 
diameter of the gut ; and I think the o- 
peration may be performed with the 
fame degree of fecurity, and in a man- 
ner that will obviate this difficulty, by 
entering the needle always from the in- 

fide 



Seft. XII. in the Abdomen. 279 

fide of the gut, and pufliing it outward. 
The operation {houlci commence near to 
one end of the wound : the needle being 
puflied through one fide of the gut, the 
ligature ftiould be drawn forward and re- 
tained by a knot formed on the end re- 
maining in the infide. The needle muft 
now be carried ftraight acrofs and en- 
tered in a fimilar manner, fo as to pierce 
the oppofite fide of the wound alfo from 
within; but the following and every 
fucceeding flitch will not be oppofite to 
each other. When the operation is righ- 
ly performed, the needle will be carried 
from one fide of the wound in a diagonal 
line to the other, and will enter the gut 
at the diflance of two-tenrhs of an inch 
from the point which it came from on 
the oppofite fide. In this manner the 
fides of the wound may be dra.wn clofely 
and exadlly together, without lefTening 
the diameter of the gut in any degree ; 
and the end of the ligature may at laffc 
be fecured and cut off clofe to the other 
extremity of the wound, if the ,gut is to 

be 



2 So Of Wounds Ch. XXXVL 

be put freely into the abdomen ; or it 
may be left of a fufficient length to hang 
out at the wound in the teguments, if it 
is the meaning of the operator to retain 
the wounded part of the inteftine in con- 
tadl with the external opening. This 
indeed is ufually done, that we may 
have it in our power, as it is faid, to 
draw away the ligature on the wound 
of the gut being cured. It is proba- 
ble, however, whatever future may be 
employed, if more than one or two 
flitches have been paffed, that it will be 
very difEcult, and even uncertain, to 
get the ligature away, without hurting 
the inteflines more than we ought to 
do. I would never advife, therefore, 
with any view of this kind, that the liga- 
ture fhould be left out at the wound ; lefs 
danger will arife from cutting it entirely 
away, and allowing the ftitches to re- 
main : a confiderable part of it will fall 
into the cavity of the gut ; and in fuch 
circunjftances the danger of the patient 
from other caufes is fo great, that any 

addi- 



Sea. XII. in the Abdomsn. 281 

additional rifk that can occur from the 
remaining part of it, mud be fo trifling 
as not to deferve notice. But in exten- 
five wounds of the intellines, where there 
may be much caufe to fear that the ope- 
ration will not prove fuccefsful, with a 
view to prevent the faeces from being 
emptied into the abdomen, it may; be 
proper, by means of the thread ufed for 
the ligature, to retain the injured part in 
contact with the wound in the perito- 
neum. But of this we fhall prefently 
fpeak more particularly. 

This is the method of treatment which 
we would advife when the gut is not cut 
entirely acrofs ; and, however fmall a 
wound of the inteftines may be, it ought 
always to be fecured with a ligature : 
for although it is alledged by fome 
authors, that we fhould rather truft 
to nature for the cure of a fmall open- 
ing here than to infert a ligature j to 
me it appears that their opinion is by- 
no means well founded ; infomuch that 
I would not leave eveti the fmalleft 

Vol. V. T open. 



282- Of Wounds Ch. XXX VE 

opening that could admit either fseces 
or chyle to pafs without flitching it up. 
But where any part of the alimentary 
tube is cut completely through, fome 
difference will be neceflary in the me- 
tiiod of management. 

When both ends of the divided gut 
protrude at the wound, it ought to be our 
obje(5l to bring them into conta6l in fuch 
a manner as to admit of their uniting. — 
There are different modes of effeding 
this. It has been done by flitching the 
two ends of the gut to the peritonaeum 
and abdominal mufcles, exadly oppofite 
and contiguous to each other ; and al- 
though the fsEces muft in this manner be 
evacuated for fome time by the wound, 
yet different inftances have occurred of 
the two ends of the gut adhering firmly 
together, and being completely united in 
the courfe of a very fhorc time : Of this 
two cafes have fallen within my own ob- 
fervation. 

In fuch circumflances, we are com- 
-monly advifed to plug up the opening ia 

tha. 



Seft. XII. in the Abdomen. 283 

the end of the upper extremity of the 
gut, not only with a view to keep the 
patient clean and comfortable, by pre- 
venting the fsEces from being at all times 
puflied out, but to prevent, as we are 
told, the gut from contraifling and from 
being diminiihed in its disfmetcr. I am 
convinced from experience, however, 
that this precaution is very unneceflTary ; 
and I know that it proves hurtful. In- 
ftead of introducing tents or doffils of 
any kind, the outward (ore fhould be 
dreffed as lightly as polfible ; and if care 
be taken to keep the patient clean, the 
reft (liould be trufted entirely to na- 
ture. 

This is, perhaps, the beft method of 
managing this variety of wound ; but 
the fame intention may be anfwered by 
inferting the upper extremity of the di- 
vided gut into the end of the other, and 
flitching them together. In this fitua- 
tlon it would be difficult to draw the di- 
vided parts together with a needle and 
ligature, without hurting the oppofite 
T 2 fides 



284 Of Wounds Ch. XXXVI. 

fides of the gut, in any other way thari 
by keeping it extended by means of fome 
round body inlerted into it. For this 
purpofe it has been propofed to make 
u/e of a tube of thin pafteboard or 
paper ; but as this might be laid hold 
of and kept firm by the ligature, a 
fmall roll of tallow is preferable, as it 
will afterwards melt and pafs eafily off 
with the fasceS' A piece of it, nearly 
equal to the diameter of the intefline, 
fhould he inferted into the end of the 
tipper portion of the gut j and being af- 
terwards paffed into the other, fo as to 
carry the one, to the extent of an inch or 
thereby, fairly into the other, the two 
portions Ihould now be flitched together 
with a fmall needle armed with a fine 
thread. The flitches fliould be carried 
completely round the gut ; and in order 
to give them as great a chance as poflible 
of fucceeding, they might even go twice 
round; firfl at the edge of the under 
portion of gut, and afterwards about an 

inch 



Se£t. XII. in the Abdomen, 285 

inch beneath, near to where the upper 
part of it terminates. 

In the infercion of one extremity of 
the gut within the other, we have de- 
fired, for an obvious reafon, that the end 
of the upper portion fliould be put into 
the other ; but it requires fome attention 
to make the dirtindlion. The periftaltic 
motion will be obferved to be more re- 
markable in the upper divifion than in 
the under : But the moft certain method 
of judging, is to obferve at which of the 
ends the fasces or chyle are evacuated. 
An inverlion of the ufual motion of the 
bowels might indeed produce a decep- 
tion ; but as this is not a common oc- 
currence, we are not to fuppofe that at 
this particular time it is likely to hap- 
pen. 

In wounds of thefe parts, a portion of 
divided gut fometimes hangs out at the 
wound, while the other end of it has flip- 
ped into the abdomen. In fuch circum- 
ftances, authors in general advife the end 
of the gut to be ftitched to the perito- 
T 3 nsEum, 



j?86 Of Wounds Ch. XXXVI, 

nseum, and other parts contiguous to the 
wound. If it proves to be the upper 
part of the gut, the patient, it is faid, 
may live under the inconvenience of an 
artificial anus ; and if it be not near to 
the upper part of the fmaller inteftines, 
that a fufficient quantity of chyle may be 
carried into the blood for hisfupport and 
nourifliment. But in the event of this 
proving to be the under part of the gut, 
although death would certainly enfue 
were we to reft fatisfied with this, it has 
fcarcely been fuppofed that we ought to 
proceed farther. 

I am clear, however, that this will not 
prove fatisfadlory to the feelings of any 
prartitioner poflefTed of that degree of 
fortitude which our art requires, and 
who has that regard for the fafety of his 
patient which every furgeon ought to 
poiTels. And although I have advifed, 
in wounds of the inteftines, when no 
part of them protrude, where we cannot 
therefore know whether the wound be 
l^r^e or only a fmall pundure, and 

wherf 



Scft. XIL in the Jodome?:, 287 

■where the injured part may be fo fitua- 
ted, that it could not be reached without 
opening the greatest part of the abdo- 
men, and turning out perhaps the whole 
ahmentary canal, that we had better al- 
low the patient to have the chance of 
recovering without any attempt to make 
a difcovery, and which he may do if 
the wound is fmall, than to propofe a 
meafure, which of itfelf might be attend- 
ed with more hazard than the injury for 
which it was meant to be a remedy. — 
Yet, when we are rendered certain of 
the gut being completely divided by one 
end of it hanging out of the wound, as 
this will give much caufe to imagine that 
the other is at no great diftance, I think 
it ought by all means to be fearched for, 
by enlarging the external wound fo as to 
admit of the fingers of the operator be- 
ing freely inferted. Even where the 
upper part of the gut is protruded, it is 
worth while to fubmit to this inquiry, 
merely in order to have at lead fome 
chance of avoiding the loathfome incon- 
T 4 yeniencp 



m Of Wounds Ch. XXXVI. 

venience of an artificial opening for the 
fsces ; And where the upper part of the 
gut has flipped in, the patient can have 
no chance for farther exlflence if it be 
T'Ot difcovered. In luch a fituation, there- 
fore, we fhould not heCitate as to the mear 
fures. 

In wounds of the abdomen, the in- 
teflines, beCdes being protruded and 
wounded, are fometimes mortified ; and 
they are fometimes mortified without be- 
ing wounded. But whether mortification 
be combined with a wound or not, the 
method of treatment fhould be nearly the 
fame. 

Where there is only a tendency to 
gangrene from the parts being much in- 
flamed, they fhould be returned immedi- 
ately into the abdomen, for the reafons 
we have given in a preceding part of this 
fedlion. But whenever they are entirely 
mortified, the black dead fpot will foon 
fall out ; and the remainder being thus 
!ced nearly to the ftate of a fore 

fron> 



Seft. XII. in the Abdomen. 289 

from any other caufe, the fame method 
of cure w ill become applicable. 

Authors, in general, have treated of 
wounds of the fmall and great inteftines 
feparately : but no neceffity appears for 
this ; they are nearly of the fame nature, 
and require the fame method of treat- 
ment. The fmalleft injury done to the 
bowels is always hazardous, and in every 
inftance of it our prognofis {hould be 
doubrful. But it is faid, that wounds in 
the imaller inteftines are more particu- 
larly dangerous than in the others ; from 
their being more apt to induce violent 
degrees of inflammation : I have not ob- 
ferved, however, that this is confirmed 
by experience. 



% S' ^f Wounds in the Stomach, 

In wounds of the abdomen, we con- 
clude that the ftomach is injured, from 
the part at which the inftrument enter- 
ed, and from the depth and diredlion ia 

which 



290 Of Wounds Ch. XXXVI. 

•which it appeared to run ; from the pa- 
tient being feized with a vomiting of 
blood ; from his complaining of a great 
and unufual degree of ficknefs ; of lan- 
guor and fmgultus ; and from the food 
and drink being evacuated at the wound 
foon after they are fwallowed. 

All wounds in the upper part of the 
kft hypochondrium which pafs to any 
confiderable depth, as likewife thofe of 
the epigaftrium, will neceffarily enter 
the ftomach ; but wounds of any part of 
the abdomen may reach it when they 
run in an oblique diredion : And it 
ought to be noticed, as we have elfewhere 
obferved, that wounds may penetrate this 
vifcus when it is full, which would not 
touch it when empty. 

Wounds of the flomach mufl; always 
be confidered as dangerous, and a doubt- 
ful prognofis only fhould be given ; for 
although there are many inftances on re- 
cord of their being cured, yet this is by 
no means fo common as to warrant our 
expecfling it. 

The fame plan of treatment which we 

have 



Seft. XII. in the Abdomen. 291 

have advifed In wounds of the inteftlnes 
applies with equal propriety to wounds 
of the ftomach. When the wounded 
portion protrudes, it fliould be Ititched 
up and replaced as quickly as poflible. 
But even where it does not protrude, it 
ought to be fearched for ; and when the 
anterior part of the flomach only has 
fuffered, it will not be difficult to dlfco- 
ver it. We fliould not, however, be de- 
terred from the inquiry by the feat of 
the wound ; for we may be able to reach 
it wherever it may be, excepting in the 
poflerior part of the flomach. 

It is to be obferved, that wounds of 
the ftomach are more readily difcovered 
than wounds of the inteftlnes ; for thefe 
laft are more concealed by convolutions 
of themlelves, as well as by other vif^ 
cera. 

In all wounds of the ftomach and 
bowels, the patient fliould be put upon 
as ftrldl a regimen as his ftrength will 
bear: not only with a view to prevent 
the acceflion of inflammation, which, as 

we 



292 Of Wounds Ch. XXXVI. 

we have formerly obferved, is the mod: 
dangerous fymptom that can occur, but 
to prevent che injured parts from being 
diftended, by which they might be very 
materially hurt. In (lead of regular 
meals, a fpoonful or two only ftiould be 
allowed at once ; and no more given 
even in this way than is merely necefTary 
to fupport life. Ip wounds of the fto- 
mach and upper part of the fmaller in- 
tefllnes, we might venture in a great 
meafure, and at lead for feveral days to- 
gether, to trufl to nourifliing glyflers: 
but this fhould be carefully avoided in 
wounds of the great guts ; as the injecfl:- 
ed liquor mi2;ht more readily be forced 
in this way into the cavity of the abdo- 
men than if it had been taken by the 
mouth. 



% 6. Of Wounds of the Omentum and Mefentery. 

We have alreadj'- mentioned the fitua- 
tion of thefe parts. But we have no 

means 



Seft. XII. in the Abdojnen. 293 

means of judging whether they have fut- 
fered by wounds of the abdomen or not, 
if they be not protruded. 

When it is found diat a protruded por- 
tion of omentum is injured, we ought to 
fee whether any part of it be nearly fe- 
parated from the reft or not : for what- 
ever part of it is in this (late ftiould be 
immediately removed ; or when it has 
become cold, with much reafon to dread 
that it will mortify, it will likewife be 
proper to remove it. But when no ap- 
pearance of this kind takes place, we 
fliould advife it to be immediately return- 
ed into the abdomen. 

In the Firft Volume of this Work, we 
found it neceflary to enter upon the con- 
fideration of this fubjed: when treating 
of Hcrniae : It will therefore be proper 
to refer to what we had then occafion to 
fay upon it. 

In wounds of the mefentery, what we 
have mod to dread is the difcharge of 
blood or chyle into the cavity of the 
abdomen ; for as the kdteals, together 

with 



294 0/ Wounds Ch. XXXVI. 

with a great number of arteries and veins, 
run in the duplicature of this membrane, 
it can fcarcely be injured without fome 
of them fuffering. Whenever any por- 
tion of it, ther fore., is protruded, ic 
ought to be examined with accuracy : 
and when any of its vefTels are found to 
be divided, they fliould be immediately- 
tied with ligatures ; the ends of which 
being left out at the wound, will admit 
of their being taken away as foon as they 
are thoroughly feparated. 



§ 7. Of Wounds of the Liver and Gall-bladder. 

From the anatomical defcription we 
have given of the contents of the abdo- 
men, it appears that the liver will be ve- 
ry apt to be hurt by all wounds that pe- 
netrate either the right hypochondrium 
or epigaftrium. 

The liver does not appear to be pof- 
fefTed of much fenfibility ; for many in- 
ftances have occurred where fuperficial 

wounds 



Seel. XII. ' in the Abdomen. 295 

wounds in it have healed with the fame 
eafe, and have not induced any more 
alarming fymptoms than what ufually oc- 
cur from wounds of the fame extent in 
any other part of the body. But wounds 
of this vifcufa, which pals to any confider- 
able depth, arc always to be confidered 
as dangerous, from the great quantity of 
blood which is fent to it, as well as from 
the interruption which they may give to 
the formation of bile, one of the moft 
important fecretions in the body : And 
they are apt to prove particularly ha- 
zardous, from their allowing the bile, 
which is very foon rendered putrid, to 
be poured into the cavity of the abdo- 
men. 

We judge of the liver being injured, 
from the fituation and depth of a wound ; 
from the quantity of blood that is dif- 
charged being more confiderable than 
could probably be afforded by any blood- 
veiTels of the integuments or rnufcles ; 
from bile being difcharged along with 
the blood: from bile tinged with blood 

being 



c.gG Of Wounds Ch. XXXVL 

being carried into the bowels, and dif- 
charged both by the ftomach and anus ; 
from the abdomen being apt to fwell and 
become tenfe ; and from pain being felt 
on the top of the flioulder, an ufual 
fymptom in difierent afFedlions of the 
liver. 

All that we can do in wounds of this 
vifcus, is to guard as much as pofTible 
againft exceffive hemorrhagies, and to 
difcharge any co]ie(flions of blood or of 
bile that may form in the abdomen, when 
they become fo conliderable as to render 
it neceffary. We endeavour to prevent 
or put a Hop to the hemorrhagy by 
blood-letting,' gentle laxatives, keeping 
the patient cool, and at perfed red both 
in body and mind. And we difcharge 
colledions of this kind, by m.aking an 
opening in the moft depending part of 
the abdomen, or wherever they may hap- 
pen to form. 

Wounds of the gall-bladder are by ex- 
perience found to prove more dangerous 
than wounds of the liver ; for they are 

fliU 



Sed. XII. in the Abdoment a^y 

ilill more difficult to heal, at the fame 
time that they are more certainly pro- 
dudlive of extravafation of bile into the 
abdomen. Inftances indeed have hap- 
pened of the bile being fo completely ob- 
(lru6led in its palTage from the gall-blad- 
der to the dnodenum, that the bladder 
has fwelled fo as to produce much exter- 
nal tumefa(ftion : And, in fome cafes, 
thefe fvvellings, after burfting or being 
opened, have continued to difcharge bile 
for a confiderable time ; and at laft have 
been known to heal without producing 
any extravafation into the abdomen, or 
any other alarming fymptom. This, 
however, proceeds from the previous diC- 
tention of the bladder having produced 
an adhelion between it and the neigh- 
bouring parts ; by which, when an open- 
ing is made into it, the bile is prevented 
from fpreading. But few inftances have 
occurred of wounds in this vifcus having 
a favourable termination. To procure 
as free a vent for the bile as poflible, and 
to difcharge it by an opening fuch as wc 
Vol. V. . U have 



298 Of Wounds Ch. XXXVI. 

have mentioned, when it collects hi the 
abdomen, is perhaps all that we ought to 
attempt. 



§ 8. Of Wounds of the Spleen, Pancreas, and 
Receptaadtmi Chyli, 

When the Ipleen Is laid bare, we eafi- 
ly dilcover whether it be injured or not: 
but as it does not aiford any particular 
fecretions by the appearance of which 
we might be determined, and as wounds 
of it do not excite any remarkable fet of 
fymptoms, it is difficult to judge merely 
from the depth or direction of a wound 
whether it be hurt or not. It is obfer- 
ved indeed, that the blood difcharged 
immediately from the fpleen is of a pe- 
culiar deep red colour; but this teft is 
not to be depended on : Nor are we to 
conclude from the quantity of blood be- 
ing confidcrable, which a wound in the 
region of the fpleen may diicharge, that 
this vifcus is certainly injured ; for it 

lies 



Sect. XII. in the Abdomen. ^99 

lies {o near to large blood-velTels belong- 
ing to other vilcera, particularly to the 
emulgent arteries and veins, that no cer- 
tain judgment can be formed from thi^ 
circumflance. 

The fame obfervations which we have 
made upon wounds of the liver will ap- 
ply with propriety to wounds of the 
fpleen ; only we may fuppofe, that the 
danger attending the latter will not be 
fo confiderable, as no material fecretion 
will be interrupttid by them. 

As the pancreas lies deeply covered 
with the other vifcera, wounds of it can 
feldom be difcovered : But as a divifion 
of the du(fl of this gland will prevent the 
fecretion which it affords from being 
carried to the bowels, this may, by in- 
terrupting or impeding digeftion, do 
much injury to the conftitution ; and, as 
the liquor will be effufed into the caviny 
of the abdomen, it may thus be produc- 
tive of collections, the removal of which 
may ultimately require the afHftance of 
furgery. 

U 2 Wounds 



300 Of Wounds Ch. XXSVI. 

Wounds of the receptacnlum cHyli 
will be dilVinguillied from their fiuiation, 
and from the difcharge being a thin 
milky kind of liquor. They muft ne- 
ceflarily be attended with mnch danger, 
as they will deprive the patient of the 
greateft parr, or even of all the nourifli- 
ment which he ought to derive from his 
food. They can never in any way be- 
eome the objed of forgery, but by pro- 
ducing collections in the abdomen which 
may require to be difcharged. 



5 9. (y Wounds of the Kidneys and Ureters. 

In a preceding pare of this Work *, 
we have mentioned the fituation of the 
kidneys ; an accurate knowledge of which 
is an objetl of much importance in judg- 
ing whether penetrating wounds in thefe 
parts may have injured them or not. 
But in general we may be determined 
by the fymptoms which take place. 

The 

Vidi Vol. II. Chap. XI. Sea. II. 



Sed. XII. in the Abdomen: 301 

The external coverings of the kidney- 
may be hurt without any fymptom of 
importance being induced ; but neither 
the pelvis of the kidney, nor the ureters, 
can be penetrated without fome or per- 
haps all of the following fymptoms ta- 
king place: The patient complains of 
violent pain, not merely in the part it- 
felf, but over the v/hole loins, in the 
groin, yard, and even in the tefticles ; 
he is liable to much ficknefs and vomit- 
ing ; the urine is palled with pain and 
difficulty, and along with it more or lefs 
blood is ufually difcharged ; and altho' 
the greateft part of tlie wound may heal, 
it commonly happens that a fiftulous 
opening remains during life. 

When the kidney is pierced by a wound 
entering from the belly, the urine is apt 
to be extravafated into the cavity of the 
abdomen : But when it is wounded from 
the back, or even from the fide, the urine 
will either pafs direcliy out at the open- 
ing, or it will fpread through the conti- 
guous cellular fubftance ; for as it is fi- 
ll -i tuated 



302 ■ Of Wounds Ch. XSXVL 

tuated behind the pentonaeum, it will 
not in this cafe find accels to the belly. 
The rilkj therefore, with which wounds 
of this organ are attended, will depend 
in a great mealure on this circumftance. 
When the urine paffes into the abdomen, 
the danger will be very great; but when 
this does not happen, if the patient fur- 
vives the hemorrhagy with which the 
wound is at firtt attended, he may have 
a tolerable chance to efcape, with the 
inconvenience of a fiftulous opening, at 
which the urine will continue to be dif- 
charged. Initances indeed have occur- 
red even of this being at lalt cured ; but 
ihey are fo rare, that they are fcarcely to 
be looked for. All that art can with 
propriety attempt, is to prevent the urine 
from lodging ; and, if the iides of the 
opening become callous, to render them 
raw from time to time, either with the 
fcalpel or lunar canllic, by which they 
may at laft be made to unite. 



Scd. XII. in the Abdomen. 303 



^ 10. Of Wounds of the Bladder. 

Th bladder when empty lies altoge- 
ther within the bones of the pelvis ; but 
when filled wiih urine, it riles confider- 
ably higher, infomtich that, when the 
nrine is long obltrufled, there are in- 
llances of its reaching to the umbilicus. 
In judging, therefore, whether injuries 
done to thefe parts Have penetrated the 
bladder or not, we mufl: know whether 
it was empty or full. But for the moft 
part this point is eafily determi;ied ; as 
in general the urine comes away by the 
wound, and even- that which pafTes by 
the urethra is at firll always tinged with 
blood. 

The danger from wounds of the blad- 
der is always more or lefs according to 
the fituation of the injury. As the up- 
per part of this vifcus lies within the ca- 
vity of the abdomen, being covered with 
the peritonaeum, puni!:tures in this part 
U 4 are 



^04 Of Wounds Ch. XXXVI. 

;are apt to produce an extra vafation of 
nrine into the belly, by which the mod 
dangerous fymptoms are commonly in- 
duced : while the under part of it, not 
being covered with this membrane, is 
often wounded, without any fymptom of 
importance taking place, as we daily ob- 
lerve in the operation of lithotomy as it 
is now pra(?tifed in the lateral method. 

In wounds of the under part of the 
bladder, all that we have to do is to drefs 
them in the ufual .way with fimple eafy 
applications ; while by blood-letting in 
proportion to the ftrength of the patient, 
by the ufe of gentle laxatives, and a low 
diet, we endeavour to prevent inflamma- 
tion, the moft dangerous fymptom that 
Attends injuries of this vifcus. And 
when inflammation has already taken 
place, we try to remove it by farther 
evacuations of blood, by dofes of opiates 
proportioned to the degree of pain, by 
warm fomentations to the belly, and by 
the femicupium. Indeed warmth ap- 
plied in this manner feems to have a 

more 



Se£t. XII. in the Abdomen. 305 

more certain efFed in removing the pain 
and tenfion of the abdomen, which thefe 
wounds are very apt to induce, than al- 
moft any other remedy. 

When again the upper part of the blad- 
der is injured, together with the rifk 
which occurs from inflammation, we have 
the additional hazard arifmg from extra- 
vafation of urine. 

As the danger with which this is at- 
tended is always confiderable, efpecially 
when the ur'.ne paffes into the abdomen, 
it might give the patient fome rarther 
chance of recovering, to treat wounds of 
this kind in the bladder upon the fame 
principles, and in the lame manner, that 
we have advifed for wounds of the in- 
teftines ; that is, by ditching up the 
wounded part either with the glover's 
future, or in the manner we have advi- 
fed in a preceding part of this fedlion, as 
may be feen in § 4. The glover's future 
m.ight anfwer equally well with the other ; 
and here it might be ufed with more free- 
dcin than in the inteftines, as the blad- 
der 



3o6 Of Wounds Ch. XXXVI. 

der can more readily admit of being 
fomewhat diminiQied in its capacity. 

To prev nt the inconvenience and dan- 
ger arifing from urine being extravafa- 
ted into the abdomen, it has been propo- 
fed to draw the opening in the bladder 
forward to the external wound ^ and to 
flitch it to the peritonseum and contigur 
ous parts. This may be eafily done 
when the anterior part of the bladder is 
wounded ; but when the opening lies 
behind, to draw it forward and retain 
it at the wound would be produ6live 
of much pain, and might ultimately 
be attended with more danger than it 
was meant to prevent. In fuch circum- 
ftances, I would rather trufl: to the wound 
being neatly flitched up, when the parts 
ftiould be immediately replaced, and the 
patient treated in the manner we have 
advifed for fimilar injuries done to the 
intedines. 

§11. 



Sea. XII. in the Abdomen. 307 



§ II. Of Wounds of the Uterus and its appen- 
dages. 

The uterus is a ftrong mufcular bag 
peculiar to the female iex, being folely 
intended for the foetus. It is of a tri- 
angular figure, and is fituated between, 
the bladder and reftum. In an unini- 
pregnated ftate, it lies altogether with- 
in the bones of the pelvis: but during 
pregnancy, it rifes fo high in the abdo- 
men as to touch the umbilicus and even, 
the (lomach ; while the inferior point of 
it, termed the Os Tincae, terminates in 
the vagina, a fmooth membranous (heath 
which runs contiguous to, and terminates 
below the urethra. 

The uterus is firmly attached by dif- 
ferent ligaments to the contiguous parts : 
by the ligamenta lata on eacti lide, which 
appear to be doublings of the peritonas- 
um ; and by^the ligamenta rotunda, 
^vhich ariie from the upper corners of 

the 



3o8 Of Wounds Ch. XXXVI. 

the fundus uteri, and pafling down thro' 
the openings in the external obHque muf- 
cle, are loft in the upper pare of the 
thigh. By the tubs Fallopianae, which 
arife near to the ligamenta rotunda, the 
uterus communicates with the ovaria 
two fmall round bodies placed within an 
inch and a half of its fundus. 

From the uterus ftretching, and occu- 
pying different parts in the different pe- 
riods of geftation, it is eV^ident that 
wounds, which in one ftate might injure 
it, in others will pals confiderably above 
it: fo that in judging from the fitu- 
ation and diredlion of a wound in thefe 
parts, this circumftance requires particu- 
lar attention. In extenfive wounds we 
may be determined at once by examina- 
tion with the fingers, whether the ute- 
rus be injured or not : But in others, 
where this is not admiflible, we muft be 
directed intirely by the fymptoms which 
take place. 

In an unimpregnated ftate, a wound 
of the uterus will not be produdlive of 

fymp- 



Se£t. Xil. in the Abdomen. 309 

fymptoms very different from thofe which 
occur from wounds of the contiguous 
parts. But during pregnancy, wounds 
of this organ will either induce fymp- 
toms of an approaching abortion ; or the 
quantity of blood dlfcharged outwardly 
by the wound, or that is extravafated in- 
to the cavity of the abdomen, will be 
very confiderable. At lead this will in 
all probability happen when the in- 
jury done to it is material : for during 
pregnancy , the quantity of blood fent to 
the uterus is confiderable; and we know 
from experience, that haemorrhagies 
which occur from it in this ftate, feldom 
flop till delivery is efFeded ; by which 
the uterus is allowed to contradl, fb as to 
comprcfs and fupport the injured vc(^ 
fels. 

In every ^njury therefore of this kind 
where fymptoms of abortion occur, no- 
thing fhould be done to prevent it ; and 
where they do not take place, and when- 
ever there is reafon to fufpect that the pa- 
tient may fuffcr from lofa of blood, if the 

dc- 



3IO Of Wounds Ch. XXX VI. 

delivery cannot be accompliflied in the 
ufual way, the child ihould be taken out 
by the Csefarian operation- In a fubfe- 
quent part of this Work we fha]l have 
occafion to defcribe the method of per- 
forming this operation ; but in fuch 
cafes as we are now treating of, the ea- 
fieft, and perhaps bed, method of do- 
ing it, will be to enlarge both the ex- 
ternal opening and the wound in the ute- 
rus to a fize that will admit of the ex- 
tradion of the child. In other circum- 
ftances, wounds of the uterus mull be 
managed nearly in the fame manner with 
other penetrating wounds of the abdo- 
men. 

Befides the feveral vifcera in the ab- 
domen and pelvis, which we have now 
treated of, there are large blood-veffels 
and nerves which pafs through them, 
■which are alfo liable to be wounded : 
But as no remedies with which we are 
acquainted can aflPord any relief in divi- 
fions of the nerves ; and as the large 
blood-veffels here lie too deep for any 

cbir- 



Sed. XII. in the Abdomen. 311 

chlrurgical afllflance, they very unlver- 
fally end fatally. A patient may indeed 
linger long under the paralytic fymp- 
toms which always . fucceed to injuries 
done to thefe nerves; but a divifion of 
the large blood-veffels of the abdomen, 
in every inft^nce proves quickly fatal. 

We have thus finiihed the confidera- 
tion of wounds of the thorax and abdo- 
men; and it will be pbferved, that we 
have entered minutely into it. To this 
I was induced, not merely by the im- 
portance of the fubjedl, which I confider^ 
however, as one of the mod material that 
pradlitioners meet with, but with a view 
to excite the attention of beginners to an 
intimate acquaintance with the moft 
ufeful part of anatomy, that of the tho- 
racic and abdominal vifcera. 

In the preceding fedlions we have 
treated feparately of all thofe wounds, 
which, from the fituation, or any other 
peculiarity of the injured parts, may re- 
quire any variety in the method of treat- 
ment. The extremities indeed are li- 
able 



312 Poifoned Ch. XXXVI. 

able to wounds which require a mode of 
management that has not yet been attend- 
ed to, namely, thofe wounds which are 
complicated with fraftures of the conti- 
guous bones : Thefe, liovvever, will fall 
to be confidered in the Chapter on Com- 
pound Fratftures. The only other va- 
rieties of wounds which we have now 
to fpeak of, are poifoncd or venomous 
wounds, and gunQiot wounds. 



SECTION XIII. 



Foifoned Wounds. 

TTTTOUNDS may be poifoned in va- 
rious ways : The bites of feveral a- 
nlmals, particularly thofe of the viper, af- 
ford examples of poifoned wounds ; and 
the ftings of the tarantula, of wafps and 
bees, are of the fame nature. It Is evi- 
dent too,' that poifon is conveyed to 

wounds 



SedUXIir. Wounds. 313 

wounds by the bkes of mad or enraged 
animals, particularly by the bites of mad 
dogs : And they may be poifoned by the 
matter or fecredon of various kinds of 
fores, as well as by the juices of different 
vegetables. 

The flings of wafps and bees, and 
other infetfls of this climate, although 
they mav be produ(fl:ive of a good deal of 
pain, yer (eldom terminate in any fymp- 
tom of importance: The application of 
vinegar or fpirit of wine to the part af- 
fetled immediately after the injury, "will 
often prevent that pain, tenfion, and in- 
flammation, which would otherwife fu- 
pervene : and when once thefe fymp- 
toms take place, they will for the moft 
part be more effedlually relieved by wafh- 
ing with cold water, or by immerfing 
the parts in it, than by any other reme- 
dy. For the (ling of a fcorpion, we are 
advifed to kill the animal and apply it to 
the injured part, or to cover che pare with 
a dead toad or fome other animal fuppo- 
fe€ to be of a poifonous nature. There 
is much caufe, however, to imagine, that 

Vol. V. X this 



314 Poifoned Ch. XXXVi:. 

this practice is founded in prejudice ; and 
we are told,' that of late the fame reme- 
dies have been found to prove ufeful in 
the flings of infeds in warm climates, 
that we have juft mentioned for the 
flings of bees and other infedls of thij> 
coutntry. 

As the bite of a viper proves fome- 
times formidable, at all times it deferves 
particular attention. It is true indeed, 
that it often heals eafily without any 
fymptom of importance taking place ; 
for the poifon of this animal being con- 
tained in a fmall bag at the root of each' 
tooth, which it can difcharge or retain at 
pleafure, it would appear that it does not 
throw it out if it be not much irritated. 
But as we can never judge with certainty 
whether the wound be poifoned or nor, 
we ought in every cafe to be upon our 
guard. To prevent the poifon from en- 
tering the fyltem is the objedl we Ihould 
have in view. This, however, can only 
be accomplifhed when the affiftance of- 
pra6litioners is procured immediately : 

for: 



Seai. Xlll. iVdundi. 315 

for although there is reafon to fup-- 
pofe that fome other kinds of poifons, 
^ven when applied to recent w ounds, 
do not for feveral days enter the cir- 
culation J yet we know from various 
occurrences, that this is by no means 
the caTe with the polfon of the viper, 
which commonly begins to operate 
upon the fyftem in the ipace of twelve 
or fourteen hours. The patient com- 
plains of a violent burning pain in the 
injured part, which foon begins to fwell. 
Tenfion and inflammation take place, 
not merely over the affeded limb, but 
often over the whole body. The patient 
becomes faint and languid, the pulfe 
low and feeble ; he complains of giddi- 
nefs, naufea, and vomiting ; of a fixed- 
pain in the region of the heart ; the 
whole furface of the body beconies yel- 
low like the fkin of a jaundiced patient j 
the urine appears of a deep yellow, and 
is evidently ftrongly impregnated with 
bile ; cold fweats take place, along with 
convulfive twitchings in different parts 
X 2 of 



3i6 Poifoned Ch. XXXVI. 

of the body; and if relief be not quickly 
obtained, death foon clofes the fcene. 

With a view to prevent the acceilion 
of thefc fymptoms, the injured part 
fhould either be cut out immediately, or 
ftiould be deflroyed with the adual or 
potential cautery. The looner this is 
done, the more effedual it will probably 
prove ; bur it fhould always be advifed 
as long as no bad fymptom has appeared. 
In former times fudion was much em- 
ployed for the removal of every kind of 
poifon in wounds ; in fome cafes by in- 
ftruments kept for the purpofe, but mod 
frequently by the mouth ; and it was 
found, where the fkin of the mouth was 
entire, that it might be done with fafety. 
This might frequently prove fuccefsful ; 
but where the life of a patient is fo near* 
ly concerned, that remedy only fhould be 
truaed which will with certainty prevent 
the poifon from entering the bloods 
We Qiould not hefitate therefore to ad- 
vife an immediate removal of the injured 
part ; and witiji a view to render the 

prac- 



Seft. XIII. Wounds: 317 

pracftice as efFecftual as poflible, we fliould 
endeavour to excite a plentiful fuppura- 
tion over the furface of the fore; by the 
application of {Simulating ointments, 
when the patient does not complain of 
pain and tenfion ; and by the ufe of 
emollient p-ukices, when much inflam" 
mation cakes place. 

But when it appears that the poifon 
has already entered the fyflcm, this lo- 
cal treatment of the fore is not to be de- 
pended on. In fuch circumftances, the 
application of warm oil, not merely to 
the fore, but over the whole body, has 
been much recommended ; and it is faid 
that fome advantage has been derived 
from the internal exhibition of it: two 
fpoonfuls of fine olive oil, given every 
hour, is faid to have allayed the moll vio- 
lent fymptoms which the bite of a viper 
ever excites. From fome late obferva- 
tions, however, the efficacy of this re- 
medy is much to be doubted ; and ic 
would appear that a plentiful fweat, kept 
up for a confiderable time, ^^ the moft 
X 3 cer- 



SI 8 Poifmed * Ch, XXX VL 

certain method yet difcoyered, not mere- 
ly of mitigating all the fymptoms, but of 
removing them entirely. By whatever 
pieans a Iweat is induced, it is found to 
prove ufeful : byt experience fliows, that 
fmall dofes of the volatile alkali, fre- 
quently repejjted, is to be more depended 
on for this purpofe th^n any other reme- 
dy. A particular preparation of this kind, 
cau de Uice, has been much recommend- 
ed ; twenty drops of it to be gjven every 
hour. But there is reafon to fuppofe, 
that any other form of the volatile alkali 
will prove equally effe<5tual. 

All the varieties of theriac, as well as 
many other remedies, are recommended 
for the bites of vipers ; nay, different re- 
medies are advlfed for the bite of every 
variety of this animal. But as we do not 
find that any of them are to be trufled, 
it is not neceiTary to enumerate them. 

The moft formidable wound of a pol- 
foned nature which we meet with in this 
country, is the bite of a mad animal : fpr 
s^khough indanpes daily happen of thefe 

wound? 



Scd. XIII. Wounds. 319 

wounds healing without any fymptom of 
importance enfuing, 'yet whenever they 
terminate in the hydrophobia, the utmoft 
danger is to be dreaded. -Indeed the in- 
(lances of patients recovering from this 
dreadful fymptom are fo extremely rare, 
that we defpair in every cafe of any of 
our remedies proving efFedual. A va- 
riety of noftrums have been held forth 
to the public, by which we are told the 
Jiydrophobia may not only be prevented, 
but even cured when it has ai5lually ta- 
ken place. I have not heard, however, 
of any well attefted fadl of any of them 
proving uieful- 

As a preventative of the hydrophobia, 
nothing with which we are acquainted 
can be depended on, but an immediate re- 
moval of the injured part, either with the 
fcalpel, or with the adual or potential 
cautery ; which, together with a plenti- 
ful fuppuration being excited upon the 
fore, has, in different inftances, appeared 
to anfwer the purpofe effecflually : That 
is, patients who have been treated in this 
X 4 maiiQer 



320 Poifoned Ch. XXX VI. 

manner liave efcaped, winle others bit at 
the lame time by the fame animal have 
fufFered. 

The (ooner that the part afFetJled is re- 
moved after the accident, the more ef- 
fedlual the operation will probably prove : 
but it had better be done, even at the di- 
flance of feveral days, than that the pa- 
tient lliould be deprived entirely of the 
chance which it affords ; and this efpe- 
cially as there is reafon to imagine that 
thib poifon does not enter the iyftem fo 
quukiy as a variety of others are obfer- 
ved to do ; at leaft this mud be the cafe 
if we can judge from the time at which 
it begins to operate. For we know, 
that in mol\ inrtances none of the fymp- 
toms induced by the bites of mad ani- 
mals appear till a confideiable time after 
the accident : It almoft always happens 
that feveral weeks intervene ; and it has 
been knojvn that a per ion has remained 
perfectly well after the bite for the fpace 
of fix months, and at lafl has betn fud- 
denly feized with hydrophobia. When- 
ever 



Sed. XIII. Wounds. 311 

ever we are certain, therefore^ that a per- 
fon has been bit by an enraged animal, 
we (hould advife the part to be cut out 
at whatever period this may be, provided 
no fymptom has appeared of the poifon 
havinj^ entered the fyftem : And the fore 
fhovild be kept open for a conliderable 
time by the daily application of fome ir- 
ritating ointment. 

Wiiile wc place mofl: confidence in this 
treatment, we fhould not negledl entire- 
ly any advantages which we are told 
may be derived from other remedies. — 
Sea-baching has been much tamed in all 
ages as a preventative of thele fymp- 
toms : we have few well attefted cafes, 
however, of any benefit being procured 
from it. By many pradlitioners, mer- 
cury is much depended upon, particular- 
ly fridlionb with mercurial ointment, and 
the application of it to the fore ; and as 
this may be employed along with any 
other plan of treatment that may be 
adopted, it may be right in every cafe to 
advife it. 

It 



3^2 • Poifoned Ch. XXXVI. 

It will often happen, however, that 
neither thefe nor any other means we 
can employ will prove efFedual ; and as 
the province of furgery affords no reme- 
dy for the fymptoms vt'hich accompany 
the hydrophobia, as foon as they take 
place, the unhappy fufferer (hould imme- 
diately receive all the allillance which 
phyficians of experience and obfervation 
can give. 

When wounds are poifoned by the 
matter of difeafes, as fomecimes hap- 
pens to furgeons in the treatment of 
fores, particularly of thole of the vene- 
real and cancerous kinds, the beft prac- 
tice would be to remove the virus im- 
mediately, in the manner we have juft 
mentioned in cafes of poifoned bites, by 
cutting out the part afFeded, or burning 
it with a hot iron. With refped to the 
venereal poifon, a timid patient may in- 
deed hefitate in the ufe of fuch a formi- 
dable remedy, when he knows that we 
are poiTefTed of an antidote which fel- 
dom fails : Many, however, would en- 
dure 



^ect. XIII. Wounds. 323 

dure the momentary pain of a burn or a 
cut, in preference to the flow operation 
of a mercurial courfe. And in cafes of 
fores coming into contad: with the mat- 
ter of a cancer, we fliould not hefitate in 
adopting the practice immediately ; for 
hitherto we are not poflelled of any re- 
medy upon which any dependence can 
be placed for the cure of this difeafe. 

This would likewife be the mofl: eli- 
gible practice in wounds infe<fl:ed with 
any of the vegetable poifons. We are 
told, however, that in thole parts of the 
world wliere alone it can be necellary, 
antidotes are univerfally known for 
every poilbn of this kind ; and that the 
Indians, when they are wounded, can 
difcover immediately whether the iuf 
ftrumenis with which ihey are hurt have 
been poifoned or not. 

With refpecfl to the metallic poifons, 
they do not at prefent fall within our 
confideration ; for however deleterious 
they prove when taken into the llomach, 
they do not appear to prove otherwifp 

hurttui 



324 Poifoned Ch. XXXVI. 

hurtful when applied to wounds, than by 
irritating or corroding the parts with 
which they come in contacf^ We are 
told, indeed, that inftances have occur- 
red of thefe poifons entering the fyftem 
even when applied to wounds ; and this 
is mentioned as a reafon for our not 

^ ufing the different preparations of lead 
with fuch freedom as is now univerfally 
done. But although remedies of this 
clafs are daily employed by almoft every 
practitioner, we have not heard of a 
lingle well marked caie of their proving 
in any degree noxious: Nay, it is to be , 
doubted, whether even the fait or fugar 
of lead, as it is termed, proves hurtful, 

- even when taken in confiderable quanti- 
ties into the floraach. We know that 
in fmall dofes it may be uled with per- 
feift fafety ; and I have much reafon to 
think that it may be taken even in large 
quantities with more freedom than is 
commonly imagined, from its having 
happened in different inftances with pa- 
tients of my own, who by miftake have 

fwallowed 



Sea. Xir. Wounds. 325 

fwallowed and retained a large cupful of 
a ftrong folutipn of faccharum faturni, 
without any bad fympcom enfuing. 



SECTION XIV. 



Of Gun/hot Wounds. 

AS wounds made by fire arms are fup- 
pofed to be very different from eve- 
ry other kind of wound, they are ufual- 
ly treated of in feparate chapters. We 
think it right in fome meafurc to adhere 
to a cuftom which has long prevailed : 
but at the fame time we mud obferve, 
that this difference conlifts chiefly in the 
fymptoms being for the moft part more 
fevere and violent in gunlhot wounds 
than in others. Till of late, moft of the 
fymptoms induced by gunfhot wounds 
were fuppofed to originate from poifon 

carried 



o 



215 Of Gunjhot Ch. XXXVL 



Carried in with the ball ; and it was al- 
fo imagined, that the hall cauterized or 
burned the parts as it paffed along. We 
now know, however, that thefe opinions 
'are both ill founded; that the injured 
parts do not fuffer either by poifon or 
from the immediate application of heat ; 
and that all the phenomena in any re- 
fpe£l peculiar to wounds of this kind, 
proceed from the violent contufion pro- 
duced by the paflage of the ball. Of 
this we are rendered certain, frorh there 
beinw no poifon contained either in gun- 
powder or in any of the articles of which 
bullets are ufually made ; and from ob- 
ferving that fymptoms of a fimilar na- 
ture are often induced by contufed 
wounds produced by very different 
caufes. 

1 would therefore conclude, that gun- 
fliot wounds are altogether of the con- 
tufed kind ; an idea confonant to the 
method of cure, and which will tend to 
do away that myftery which has hither- 
to overihaded this branch of praftice. 

It 



Seft. XIV. Wounds. 327 

It has been a prevailing opinion, that 
there is fomething fo Angular in the na- 
ture of thefe wounas, as to render it im- 
proper for any pradlitioners to take the 
charge of them, but fuch as have had op- 
portunities of attending fleets and armies, 
and of ferving as it were an apprentice- 
ship to this branch of practice. There is 
no good foundation, hov/ever, for this 
opinion; and I have no hefitation in fay- 
ing, that gunfhot wounds Ihould be ma- 
naged upon the fame principles, and in 
the fame manner, with wounds of any 
other kind attended with an equal degree 
of contufion. 

In gunfliot wounds, the fymptoms we 
have moft reafon to dread are, inflamma- 
tion, gangrene, and a fuppuration fo abun- 
dant as to exhauft the ftrength of the pa- 
tient. Thefe are therefore to be chiefly 
kept in view, and our pradice will be 
more or lefs fuccefsful in proportion to 
their mildnefs or feverity. In fome cafes 
the contufion is fo violent and extenfive, 
that the patient fuffers from the injured 
parts being immediately attacked with gan- 
grene. 



.328 Of Gunjhot Ch. XXXVI. 

grene. But, for the mofl: part, inflam- 
mation is the fymptom from which the 
greateft danger arifes ; for if it be not 
kept moderate from tlie firft, it is apt to 
terminate either in gangrene or in exten- 
five colle(5lions of matter. 

To prevent or remove inflammation 
fhould therefore be confidered as our 
firft obje(5l in every cafe of gunfhot 
wound ; and as nothing tends v^ith (uch 
certainty to accomplilli this as local 
blood-letting, any veins or arteries that 
have been divided by the injury fhould 
be allowed to difcharge freely before 
they are tied : Excepting indeed where 
feme of the larger arteries have faffered, 
I believe it would be a good general 
rule for pradlitioners not to interfere in 
checking any hemorrhagy that may take 
place. In this they would be warranted, 
not merely by th'" known powerful ef- 
fe{5ls of local blood-letting in prevent- 
ing inflammation in general, but by 
manv well attefted fa(5ls» which tend to 
Ihow that it proves Hill more particularly 

ufe- 



Sea. XIV. Wounds. 329 

ufefal in cafes of gunHiot wounds. A- 
mong other proofb of this it may be men- 
tioned, what almofl: every army furgeoa 
has obferved, that fome of the mod re- 
markable cures have occurred among 
thofe patients who from necefficy have 
been left for a confiderable time up- 
on the tieid of battle ; by which much, 
more blood is in general loft than ulually 
happens with fuch as either from their 
rank or other circumftances are more 
early taken care of. In every caf^, there- 
fore, of gunftiot wound, we fhould at once 
determine to take as much blood as the 
flrength of the patienr will permit ; and 
where the parts are fo much contufed, 
that the veflfels which have been divided 
do not afford a fufficient quantity, (a cir- 
cumftance v^hich frequently happens,^ in- 
flead of taking it from the arm or any 
diftant pare of the body, it lliould be 
drawn off by the application of a proper 
number of leeches to the injured parts ; 
or when thefe are wanting, by cupping 
and fcarifying the contiguous Ibund 
Vol. V. Y parts. 



330, Of Gunjhot Ch. XXXVI. 

parts. In general, if this pradice be 
carried a proper length at firfl:, the ac- 
eeilion of inflammation will be prevent- 
ed ; but when it proves otherwife, and 
when the parts afterwards fwell and in- 
flame, the operation fliould be repeated 
once and again according to circnm- 
fl;ances. 

Our next objedl is to remove any ex- 
traneous body that may be lodged in the 
tvound, as far as this can with propriety 
be done. Wiien a ball has not penetra- 
ted deep, and efpecially when the wound 
is left entirely open, by a portion of fkin 
and teguments being completely remo- 
ved, there will be little difficulty in clear- 
ing away whatever might prove hurtful. 
But when a wound is found to run to a 
eonfiderable depth, and efpecially if a 
counter opening has not been made by the 
ball palling out at the oppofite fide, any 
fearch that is made for extraneous bo- 
dies, fliould be done with much care and 
circumfpecflion. When treating of Punc- 
tured Wounds in Se(5tlon III. of this 

Chap- 



Sea. XIV. Wounds. 33? 

Chapter, we entered upon the confidera- 
tion of this point. We mufl now refer 
therefore to what was then faid ; and at 
prefent (liall confine ourfelves to this ob- 
fervation, that when extraneous bodies 
lodged in gnnfliot wounds can be taken 
awa5'^ without fretting or injuring tb«- 
contiguous parts conliderably, they oughc 
always to be removed immediately : but: 
when much pain is excited, or a high de- 
gree of inflammation endangered by the 
attempt, we ought to defift. In fucli 
circumftances, it will be better to trult 
to the extraneous bodies being after- 
wards difcharged along with the matter 
of the fore ; to nature prefling them out; 
or to the parts in which they are lodged 
being accuftomed to their refidence. 
From much experience we know, that ia 
almofl: every inftance bullets fhould be 
allowed to remain in whatever part they 
are lodged, rather thap that much force 
fliould be employed in extradting them. 
A ball lodged in the fubftance of a bone, 
is perhaps the only exception to this gc- 
y 2 neral 



' 532 Of Gunjhot Ch. XXXVL 

neral rule : It cannot indeed be extrad- 
ed from this fituation but with much dif- 
ficulty ; and therefore it is in general 
allowed to remain. I have known feve- 
ral in fiances of this ; but in all of them 
much pain and danger to the patient, as 
»-'.vell as trouble and perplexity to the prac- 
titioner, were the confequences. The 
unyielding nature of bone, occafions, up- 
on the lodgement of a foreign body in its 
fubflance, great pain, tenfion, and fwell- 
ing over all the contiguous parts. To 
prevent thefe, the extradlion of the ball, 
when it can be done without hazard of 
the patient's life, fhould be attempted, as 
foon after the accident as poffible, and 
before the parts become fwelled and 
pained. 

Different forceps have been invented 
for extrafling bullets from wounds, and 
fome have propofed fcrews for this pur- 
pofe : Scarcely any of thefe inftruments, 
however, have anfwered the purpofe for 
which they are intended ; and except- 
ing where a bullet can be eafily laid hold 



Sea, XIV. Wowids, 333 

of with common forceps, no inflrumenc 
of this kind fhould ever be employed : 
for, beGdes tearing and irritating the in- 
jured parts, they are apt to catch the 
contiguous mufcles, or other foft parts, 
by which much mifchief mufl necef- 
farily be done. There mud always be 
a rifle of this w'len the wound runs 
deep ; but it ought to be more par- 
ticularly avoided in wounds of the tho- 
rax and abdomen, where laying hold 
of any of the contiguous parts would ne- 
celFarily be produrtive of danger. When 
a ball is not deeply lodged, but lies near 
to the mouth of the wound, Co that the 
,furgeon can fee it, the forceps may with 
fafety be employed j but whenever ic 
lies deeper than this, if it be judged pro- 
per to excratt it, a Counter Opening, as 
it is termed, fhould be made upon it, fo 
as to admit of its being taken out with 
the fingers. It will commonly happen, 
indeed, that balls may be extracted with 
much more eafe both to the patient and 
furgeon, by judicious openings of this 
Y 3 kind. 



534 OfGmJhot Ch. XXXVL 

kind, than by the ufe of forceps or any 
other inltrument. The pain and terror 
■which the making of thele openings are 
fuppofed to excite, ai:e the principal ob- 
jedions to them ; but it iliouki be re- 
membered, that in fuch circumftances, it 
is not the prefent eafe and conveniency 
of the patient that fo particularly merit 
our attention, as his future advantage and 
fafety. Nor will the pain induced by 
cutting direftly upon a bullet be fo con- 
liderable, as by tearing it out from a deep 
wound with forceps. 

Where the courfe of a ball is of a conr 
fiderable length, this will always be the 
cafieft method of taking it out, when the 
pradice is not forbid by the contiguity 
of large blood-velTels and nerves : But 
when the wound is only of a (liort ex- 
tent, inftead of cutting upon the ball, by 
making a fmall opening into it, it an- 
fwers better to lay the wound open thro' 
its whole length ; by which the ball is not 
only more eafily extraded, but the cure 
15 afterwards much more readily accom- 
pli Hied. 



Sect. XIV. Wounds. 335 

plHhecJ. Indeed this practice fliould be 
adopted in all fuch cafes, even when the 
ball is not lodged. When the two open- 
ings made by the entrance and exit of a 
ball are not very diftant from each other, 
and when with fafety they can be laid 
into one, it fliould always be done as foon 
as poflible after the accident ; by which 
the vefTels which have been injured will 
be more freely unloaded than they could 
poilibly be in any other manner; every 
kind of extraneous matter that the ball 
may have carried in, will be brought in- 
to view; and the fides of the finus being 
allowed to collapfe, the fize of the fore 
will thus be diminiflied. 

This being done, the parts affedled 
fliould be covered with a pledgit of any 
emollient ointment fcH^med merely of 
wax and oil, and a poultice of bread and 
milk {hould be laid over the whole: a 
practice which proves much more fuc=- 
cefsful, as well as more agreeable, than 
the app ication of warm fl;imulating 
idreffings ; which, till of late, were unj- 
Y 4 verfally 



^ 33^ Of Cunjhof Ch. XXXVI. 

verfally iifeH in every cafe of gunfhot 
wound. The pain and irritabiVny which 
ahnoli nnifornily aitend injuries of this 
kind, point ont the propriety of the mod 
foothing applications. For the molt 
part thofe we have mentioned anfwer 
the purpole : but in foaie cafes the pre- 
parations of lead anfwer better; parti- 
cularly Goulard's cerate, or the common 
wax ointment, impregnated with a fmall 
proportion of Saccharum Saturni. An 
opiate (liould now be adminiflered ; and 
the part affedled being placed in the ea- 
fiefl and moft convenient poflure, the 
patient (liould be laid to reft. 

Ihe' formation of matter in every fore 
attended wich contufion, is an object of 
■ the firft importance ; for till this takes 
place, there is often reafon to fufpeft that 
pran;yrene may fupervene. With a view 
to h alien it, the warm poultices lliould 
be frequently renewed : and they fliould 
be continued till the tenfion and fwelling 
with which wounds of this kind areufual- 
ly attended, be removed, and till the fore 

bag 



Sea. XIV. Wounds. 337 

has acquired a red healthy granulating 
appearance ; when it will fall to be treat- 
ed in the manner we have already advi- 
fed for fores proceeding from any other 
caufe. 

Gunfhot wounds are commonly de- 
fcribed as being covered from the firft 
with deep floughs or efcars ; and vari- 
ous remedies are advifed for removing 
them. Every appearance, however, of 
this kind with which they are attended, 
proceeds entirely from contufion ; and 
excepting the injury be large and exten- 
{ive, the flough covering the wound is 
not often perceptible ; or it is fo thin, 
and inconfiderable, that it diffolves and 
comes away with the matter of the firft 
or fecond drefling. In fuch cafes, there- 
fore^ it requires no particular attention. 
And even when it runs to a greater 
depth, it commonly feparates, fo as to be 
eafily removed as foon as a free forma- 
tion of matter has taken place : for eve- 
ry flough of this kind is a real mortified 
fpot ; and we have elfev.fhere fhown that 

nothing 



338 * Of Gunjhot Ch. XXXVI. 

nothing tends to feparate mortified parts 
with fuch certainty from thole that are 
found, as a free luppuration being indu- 
ced upon them. 

In the early ftages of gunfliot wounds, 
emollient poultices prove more ufeful 
than perhaps any other remedy : But it 
is necelTary to remark, that they Ihould 
not be continued alter the efFet^s we 
have mentioned are produced: for when 
they are too long perlifted in, they not 
only tend to relax the parts too much, 
and to render them foft and fpongy, but 
are apt to induce too copious a for- 
mation of matter ; from which the pa- 
tient is now in greater danger than from 
any other circumllances attending his fi- 
tuation : For although it is a point of 
the utmoft importance, in every gunfliot 
wound, to encourage the formation of 
pus to a certain extent; yet we find uni- 
verfally, that in great quantities it proves 
very prejudicial, and when once excited, 
that it is vv^ith much difficulty checked. 
We think it alfo right to obferve, that 

this 



Sea. XIV. Wounds. 



339 



this fuperabundance of matter is very- 
apt to proceed from a different catife, 
from the inflammation being allowed to 
run too high, by which extenlive efFu- 
fions and confequent abfcefTes take place 
among the contiguous mufcles. This 
cannot in any way be fo effedually pre- 
vented as by very copious bleedings im- 
mediately after the injury is inflidled : 
It is chiefly with a view indeed to pre- 
vent this diflrefsful occurrence, that we 
have advifed the pra6lice of early and 
copious blood-letting in every cafe of 
this kind ; and with thofe who have had 
opportunities of feeing the inconveni- 
ences which arife from thofe extenfive 
fuppurations that enfue from negledling 
it, no other argument will be required 
to fhow the propriety of adopting it. 

In whatever manner a too copious 
flow of matter has been induced, the 
pradlice to be adopted mufl be the fame. 
Every colle(5lion that appears muft be 
difcharged by a depending opening ; the 
iimb ftiould be laid in that poflure which 

will 



34Q Of Gunfhot Ch. XXXVL 

will moll readily admit of its running 
oiF; the patient fliould be fnpported by 
a light nourifhing diet ; and the bark 
ftiould be plentifully exhibited. It is in 
this (late indeed of gunfhot wounds that 
bark a(fi:s with mo(t advantage ; when 
the inflammatory fyraptoms are moftly 
gone, and wh^n the patient is fufFering 
from too copious a difcharge. In this li- 
tuation it often proves highly fervice- 
able- but in order to a<^l with advantage, 
it fliould be given in confiderable quan- 
tities. Elixir of vitriol proves in fuch 
cafes a powerful addition to bark. 

When, notwithftanding a liberal ufe of 
thefe medicines, and a proper attention 
to the other circumftances we have men- 
tioned, the difcharge ftill continues co- 
pious, we will often find that it is kept 
up by detached pieces of bone, or by 
pieces of cloth, or fome other extraneous 
body having been carried in with the 
bullet. In fuch circumftances, nothing 
will tend to lefTen the quantity of mat- 
ter till the ej^traneous body be removed ; 

for 



Sea. XIV. Wounds. 341 

for w ile it remains, it will irritate and 
inflrime the contiguous parts, and effu- 
fion and fuppuration will be the confe- 
quence. The Iotc ought therefore to 
be again examined ; and any loofe body 
or detached pieces of bone that are diT- 
covered, fhould be immediately removed. 
When the irritation is kept up by pieces 
of cloth, as they ace too foft to be difco- 
vered by the probe, they are apt to pafs 
unnoticed. When there is therefore rea- 
fon to fufpecl that any article of this 
kind is lodged in a fore, fome other me- 
thod is necelTary for extradling it : And 
when the parts are fo fituated that a 
cord or feton can be introduced along 
the pafTage made by the ball, nothing 
will more readily prove fuccefsful. I 
have met with different inftances of pieces 
of cloth being brought out with the dai- 
ly drawing of a cord, which were not 
fufpeded to be lodged ; and in confe- 
quence of. which the fores were foon 
cured, after various attempts to heal 
them had been made in vain. 

We 



342 Of Gunfloot Ch. XXXVL 

We have already advifed opium as an 
ufeful medicine in the early flages of 
gunfhot wounds ; and by tending more 
efFedtually than any other remedy to 
abate irritation, it proves often fervlce- 
able in leflening the difcharge of thefe 
fores,- even when they have been of long 
duration, and when various other medi- 
cines have been employed without any 
advantage. It ought therefore to be 
prefcribed with freedom whenever the 
difcharge appears to be kept up by pain 
or irritation. 

Although in gunfhot wounds hemor- 
rhagies of importance do not always 
fucceed the accident immediately, yet 
they fbmetimes take place afterwards. 
This feems to proceed from the arte- 
ries being left open and expofed, when 
the mortified flough which contufions 
ufually produce falls off. About this 
time, therefore, pratflitioners lliould be 
much on their guard againft fuch an oc- 
currence, and this efpecially when the 
injury is extenfive, or feated near to any 

large 



Sea. XIV. Wounds. 543 

large artery. The hemorrhagy is often 
preceded by a great heat in the injured 
parts, and with a throbbing pulfatory 
pain. At this period it may frequently 
be prevented by plentifal blood-letting, 
and efpecially by the application of 
leeches to the contiguous parts ; but 
when once the hemorrhagy appears, no- 
thing will prove fuccefsful, if the vefTels 
are of any confiderable fize, but a pro- 
per application of ligatures. As the dis- 
charge in thefe cafes is often fo fudden 
and violent as to induce much hazard, 
before the afliftance of a pradlitioner can 
be procured, patients in fuch circum- 
flances fhould be furnifhed with a tour- 
niquet, with diredlions to the fervanc in 
attendance to apply it immediately on 
the firft appearance of blood. 

Hitherto we have not mentioned the 
Scarifying of gunfhot wounds ; a pradlice 
which we find recommended by almoft 
every writer upon this fubjedl, and which 
till of late prevailed very univerfally. 
By Scarifying the fores, it was expedled 

that 



344 Of Gunjhot Ch. XXXVL 

that the floughs with which they are 
fbmetimes covered would fooner fepa- 
rate, and that the cure would thereby be 
haftened. Later experience, however, 
fhows that this reafoning is fallacious ; 
and inftead of proving ufeful, that fcari- 
fying very commonly does harm : It 
creates additional pain and inflammation, 
at the fame time that it evidencly extends 
the furface of the fore, while it does not 
appear to be produdlive of any advantage. 
It iliould therefore be laid altogether 
afide. Even the dilatation of gunfliot 
wounds, fo much recommended of late, 
Ought to be employed with caution. 
When the pafTage of a ball is not exten- 
five, and when the parts through which 
it has gone can with fafety be laid open, 
I believe it would be right in every cafe 
to do it with freedom from one end of the 
finus to the other : no harm could accrue 
frpm it ; and there is reafon to imagine, 
as we have obferved above, that it would 
tend much to forward the cure : But I 
have never been able to difcover what 

advan- 



Seft. XIV. Wounds, 345 

advantages could probably be derived 
from the mere dilatation of the external 
opening of a gunftiot wound : It is pro- 
pofed with a view to give a more free 
difcharge to the matter than it would o- 
therwife have : But in deep narrow 
wounds, formed by piftol or mufkec bul- 
lets, increafing the diameter of one part 
of the finus will have no effe(fl what- 
ever upon the reft pf it ; and as it mult 
evidently do harm, by enlarging the 
wound, while no benefit can probably 
accrue from it, I do not hefitate in faymg 
that the pradl;ice fhould not be continued. 
In fuch cafes, where the wound is either 
fo fituated that it would be dangerous to 
lay it open from one end to the other, 
or where it is of too great extent for 
this pradice to be adopted, the paffing a 
cord, as we have already advifed, along 
the finus, will often anfwer our purpofe. 
This, however, fhould never be attempt- 
ed till the firft or inflammatory ftage of 
the wound is over : for while any degree 
of pain or tenlion remains, the irrita- 
VoL. V. Z tiou 



346 ' OfGiinJhot Ch.XXXVt 

tion produced by the cbrd is very apt to 
do harm. 

Biu it fometinies happe'ns even that a 
cord cannot be employed, owing to the 
iltuatiorr. and dirediion of the wound. 
In fuch cafes, after the pain, tenfion, and 
other fymptoms of inflammation are re- 
moved, and a free fuppuration is indu- 
ced j the fore mud be treated in the man* 
ner we have already advifed when fpeak- 
ing of puncSlured wounds : a proper ap- 
plication of prefTure along the courfe of 
the finus will, in fuch a (ituation, often 
effeft a cure when it cannot be obtained 
In any other manner. 

It might be expelled, that fomething 
ftiould be faid of the method of mana- 
iiinff mortification wh^n it occurs in 
gunfliot wounds; but it appears to be 
unnecefTary, as we haveelfewhere treated 
fully of this fymptom as a confcquence 
o-f inflammation * I diink it right, how- 
ever, to remark, that in gunfliot wounds 
nothing in general proves fo efftdual in 
preventing mortification as plentiful eva- 
cuations 

* Fide Treatife on Ulcers, &g. Part I.-' 



Sed. XIV. Wounds, . 347 

cuations of blood. It will not indeed pre- 
vent thofe parts from mortifying which 
have been feverely contnfed by the ball 
coming immediately into contact with 
them : but this is not what in fuch cafes 
we have mod reafon to dread ; for the 
gangrene which occurs from the contufion. 
produced by the ball, is commonly circum- 
fcribed, and it is not apt to fpread. It is 
that variety of gangrene which fucceeds 
to the inflammatory ftage of gunfliot 
wounds, of which we have moft: caufe to 
be afraid. But when blood-letting is 
freely praiflifed, it feldom takes place ; 
or if it does appear, the fame remedy will 
often prevent it from fpreading. 

As bark is found ufeful in many cafes 
of mortification, it is almoft univerfally 
employed in gangrene arifing from, gun- 
fhot wounds. I am fatisfied, however, that 
the pradice is often founded in error, and 
that much mifchief has been done by it. . 
When gangrene occurs in a weak de- 
bilitated habit, bark may always be gi- 
ven with fafety ; and in fuch circum- 
Z 2 fiances 



348* Of Gunjhot Ch. XXXVl 

ftances It will often prove to be the 
mod efFe^lual remedy. But mortification 
which takes place from gunfhot wounds 
happens mod frequently in ftrong ple- 
thoric patients, where tonics of every 
kind prove prejudicial, and where blood- 
letting and other evacuatious are particu- 
larly ufeful. In the fubfequent ftages 
even of this variety of gangrene, if the 
difeafe appears to fpread after all the 
fyraptoms of plethora and inflammation 
are removed, bark may be employed with 
propriety ; and in fuch circumftances it 
fhould be exhibited with freedom ; but 
it fliould never be given while the in- 
flammatory tenfion and pain continue. 

In offering thefe obfervations upon 
gunfliot wounds, we have hitherto been 
fuppofing that the injury is in fome de- 
gree circumfcribed, or at leafl: that it is 
not fo extenfive as to preclude hopes of 
faving the limb in which it may be fltu- 
ated ; and it is proper to remark, that 
by due cafe and attention, wounds of 
this kind may be often cured> and limbs 

faved, 



Sea. XIV. Weutids. -349 

faved, where the firft appearances were 
even very alarming. But when a limb 
is injured in fuch a manner that there is 
no reafonable hope of faving it, it would 
be improper to perfift long either in thefe 
or any other means of cure that have 
yet been propofed. By doing fo, the 
patient mull fufFer unneceflary pain and 
trouble, while at the fame time his con- 
ftitution may be fo much injured as to 
deprive him even of a chance of recove- 
ry upon the removal of the limb. But 
the attempt to fave limbs which have 
fuffered much by gunfhot wounds, gives 
rife to a queftion of importance, which 
merits particular difcufhon. 

In the various battles which occurred 
in the laft German war, the number of 
wounded men was often furprifingly 
great ; of courfe the amputation of limbs 
became frequently neceflary. By many 
it was imagined that the pradice was 
carried much farther than it ought to 
have been ; and it was even alledged, that 
limbs were often wantonly removed, 
Z 3 which 



35© Of Gunjhot Ch. XXXVI. 

which with much eafe and fafety might 
have been faved. Among others who 
were of this opinion, Mr Bilguer, fur- 
geon to the armies of his Prufhan Maje- 
fly, wrote a treatife, in which he endea- 
vours to prove, that amputation of Umbs 
is very rarely neceflary, as almofl every 
injury for which it is ufually advifed 
will admit, he thinks, of a cure, by more 
gentle means. 

As the removal of a limb fhould never 
be attempted but in cafes of real necef- 
fity, the public at large were much in- 
debted to Mr Bilguer for endeavouring 
to prevent a too general pradlice of it. 
There is much caufe, however, to ima- 
gine, that the zeal with which he appears 
to be animated has made him carry his 
reftridlions too far ; and that numbers 
would fuffer much unnecefTary pain, 
trouble, and hazard, were they to be ge- 
nerally adopted. 

Mr Bilguer thinks, that fcarcely any 
cafe of gunlhot wound can be fo bad as 
to require amputation. Even where the 

fofter 



Sea. XIV. Wounds. . '351 

fofcer parts are mucli lacerated, and the 
bones and the joints much injured, we 
ought always, he thinks, to attempt to 
fave the limb : and he alTerts, that by 
this practice more lives will be preferved 
than by the ufual method of proceeding 
immediately to amputate. After all the 
attention, however, that I have been 
able to give to a fubjedl of fuch import- 
ance, in the courfe of my own pratlice, 
and after much information obtained from 
others of experience and obfervation, I 
am of opinion, that a great deal of mil- 
chief would be done by admitting this as 
an univerfal rule. 1 would advife in every 
cafe where the flefliy parts of a limb only 
are merely divided, to make fome trials 
for faving it ; and they will often prove 
fuccefsful. Where all the mufcular parts 
of a limb are much contufed and lacera- 
ted, it would no doubt be in vain to at- 
tempt the cure of it ; on the contrary, 
it fliould be removed at once. But when 
any confiderable portion of fofc parts re- 
Z 4 mains 



352 Of tunjhot Ch. XXXVI. 

mains unhurt, although the others fliould 
be injured in the fevered manner, if none 
6f the large joints have fufFered, we 
ihould never defpair of being able to 
fave the limb. The contufed parts may 
indeed mortify and throw off, and thus 
ari extenfive fore vvill be produced: but 
•we know from daily experience, that the 
largefl: fores will heal ; and if in this we 
ihould be difappointed, we ftill have it in 
our power to advife amputation, while 
both the patient and furgeon have the 
fatisfadion to think that nothing has 
been omitted that could probably have 
prevented the neceffity of employing a 
remedy of fuch a difagreeable nature. 
And on the fubjed of Amputation we 
fliall afterwards have occafion to fhow^ 
that in fuch a fituation the operation 
proves ufually more fuccefsful when a 
fore has been of fome duration, than 
when employed immediately after the 
accident. 

But when any of the larger joints have 
been much injured by the ends of the 

bones 



Sea. XIV. Wounds. 353 

bones which conipofe them being fhac- 
tered or fpllntercd, immediate amputa- 
tion fliould always be advifed ; for the 
inflammation which fucceeds to thefe 
wounds comes on quickly ; and when 
once it takes place, the operation can 
never be employed till it be altogether 
removed. The height to which inflam- 
mation is in fuch cafes apt to proceed, 
is a powerful argument in favour of 
early amputation : for when the large 
joints are materially hurt, the parts foori 
become highly inflamed, notwithfl:and- 
ing of all that we can do to prevent it ; 
lo that no time fhould be loft in putting- 
the operation in practice. It muil in- 
deed be allowed, that out of a great num- 
ber of patients, fome few might in fucU 
circumftances have their limbs favcd, 
even where the joints have fuffered in 
the worft manner : But we cannot al- 
low, with Mr Bilguer, that this is a fuf- 
ficient reafon for the practice which he 
recommends being generally admitted. 
It is not the fuccefs which may attend 

a 



354 O/Gunjhot Ch. XXXVI. 

a few cafes, by which pradlitioners fhould 
be diredled, but that which enfues frpm 
a general courfe of pradice. And this I 
think may be confidered as certain, that 
in fuch circumftances as we are now 
confidering, more lives would be loft 
by attempting to fave the limbs of pa- 
tients, than by removing them as quick- 
ly as poffible after the injuries have been 
received ; at the fame time that the 
pradlice would be attended with much 
lefs trouble and pain to the patient : for 
the fore which remains after the removal 
of a limb is trifling indeed, when com- 
pared with extenfive lacerated wounds of 
the large joints. In the prefent impro- 
ved method of operating, the former 
often heals in the courfe of two or 
three weeks ; whereas wounds in the 
joints, even when they terminate moft 
favourably, often continue obftinate, and 
produce much perplexity and diftrefs for 
feveral months, or even for years. 

With refpedl to fradlured bones in cafes 
ofgunlhot wounds, when a large bone 

is 



Sea. XIV. Wounds. ^ 355 

is fradured or fplintered through its 
whole extent, and when this is accompa- 
nied with much laceration of the corre- 
fponding foft parts, immediate amputa- 
tion of the limb will be the fafefl: 
pradice, and ought therefore to be ad- 
vifed without hefitation. But where a 
gunfhoc wound that is not very extenfive 
is merely accompanied with a fimple 
fradlure of a contiguous bone, or even 
where the bone is fradured in different 
places, if the injury does not extend to 
the joint, we ought in perhaps every in- 
ftance to endeavour to fave the limb. 
By removing the detached pieces of 
bone, and treating the fore with atten- 
tion, we. will often have the fatisfadion 
of accomplifliing a cure, and of reftoring 
patients to the ufe of their limbs, who 
otherwife might have remained lame for 
life, or who might have been deprived of 
them intirely. 

It is proper, however, to remark, that 
although this fhould always be attempt- 
ed where a patient is to remain in a iix- 

ed 



35^ Of (iunjhoi Ch. XXXVI. 

cd fituation, and where the regular at- 
tendance of a practitioner can be procu- 
red, yet after engagements, whether at 
fea or land, where the wounded muft be 
frequently moved about, and where there 
is commonly a deficiency of furgeons, I 
believe it would be a good general rul6 
to proceed to immediate amputation in 
every cafe of gunfhot wound accompa- 
nied with a fradure of any of the conti- 
guous large bones. By doing fo, a few 
limbs would pofFibly be removed, which 
with great care and attention might have 
been preferved ; but I am convinced that 
more lives would be faved by it than 
by attempting in fuch circumftances to 
purfue any other method of treatment. 
We fhall have occafion, however, to en- 
ter more fully upon the confideration of 
this fubjedl in the Chapter upon Ampu- 
tation. 



CHAP. 



Ch. XXXVII. Of Bums, :^:ij 



CHAP. XXXVII. 



Of Burns. 

"OURNS afTume different af>pearances 
-^ according to their degrees of vio» 
lence, and to the manner in which they 
are produced. Thus, burns which mere- 
ly irritate the furface of the fkin differ 
materially from thofe which corrode or 
deflroy it ; while thofe again have a 
different afpe^l from fuch as affe(fi: the 
more deep feated parts, as the mufcles, 
tendons, ligaments, &c. : And we know- 
that fuch as occur from the application 
of boiling water, or any other liquid, 
differ materially from thofe which are 

pro- 



35^ Of Burns. Ch. XXXVIL 

produced by the direct:* conta(n: of hot 
metallic bodies, or of burning combu- 
ilible materials. 

Burns which do not deftroy the cu- 
ticle, and which irritate the fldn only, 
ad: nearly in the fame manner with can- 
tharides and other veficantia. The ir- 
ritation which they excite produces an 
increafed adlion in the exhaling veflels 
of the affedled part, by which vefications 
are formed in extent and number pro- 
portioned to the violence of the caufe. 
But when the fkin or fubjacent parts are 
deftroyed, no veficles take place. A 
black mortified flough is firfi: obferved ; 
and when this feparates and is thrown 
off, an ulcer is left of a depth corre- 
' fponding to the degree of heat by which 
it was produced. 

In every cafe of burn the pain is fe- 
vere ; but in general it may be obferved, 
that it is more confiderable where the fkirl 
has been merely much fretted or irritated, 
than where fuch a degree of heat is ap- 
plieci as %o deftroy it entirely. 

•In 



Ch. XXXVir. Of Burns. 359 

In deep extenfive burns mortification 
fometimes takes place to an alarming de- 
gree very foon after the injury is infli<5l- 
ed ; but for the moft part the fymptom we 
have mod caufe to dread is inflamma- 
tion. The pain and irritation which 
burhs excite, are in fome inftances fo vio- 
lent, that all our efforts are apt to fail in 
preventing them from inducing the very 
higheft degree of inflammation : And 
when the furface of a burned part is ex- 
tenfive, the efFe61:s of thls^infiammation 
^re not confined to the fpot which has 
more immediately fufFered ; they are apt 
to e5Ccite fever ; and in many cafes fuch 
a degree of torpor is induced, as at lafl 
ends in death. 

In the treatment of every variety of 
burn, our firft objedl fhould be to pro- 
cure eafe as quickly as pofhble. Where 
the (kin is not dellroyed, but fecms to 
fuffer merely from irritation, an abate- 
ment of pain may be procured by the 
application of remedies of very different, 

^ and 



36o Of Burns. Ch. XXX VIT. 

and even of very oppofite natures : By- 
dipping the part affedled in very cold wa- 
ter, and keeping it for fome time im- 
merfed in it, the pain will often be ren- 
dered very fupportable ; while on the o- 
ther hand, a confiderable degree of eafe 
may be procured by plunging the inju- 
red part fuddenly into boiling water, or 
any other fluid of nearly an equal degree 
of heat. Emollients are often employed, 
and in fome cafes they procure immediate 
relief; but, in general, aftringent appli- 
cations prove much more fuccefsful. 
One of the bed applications to every 
burn of this kind, is ftrong brandy, or 
any other ardent fpirits : it feems to in- 
duce a momentary additional pain j but 
this foon fubfides, and is fucceeded by an 
agreeable foothing fenfation. It proves 
moft effedual when the parts can be kept 
irtimerfed in it ; but when this cannot be 
done, they fliould be kept conftantly 
moid with pieces of foft old linen foaked 
in fpirits. The Acetum Lythargyrites, 
a ftrong folution of Saccharum Saturni, 

©r 



Ch. XXX VII. Of Burns. 361 

or Goulard's faturnine water make ufe- 
ful applications for the fame purpofe ; 
and as a proof that it is the aftringency 
of the remedy which the efFe6ls r^fuU 
from, the fame benefit is derived from ^ 
ftrong folution of alum, or even frpngi 
common ink. 

it is the common opinion, that reme"* 
dies of this kind prove chiefly ufeful by 
preventing thofe vefic^tions or ferous 
exfudations which fuperficial burns are 
ufually attended with : But I do not 
find that the obfervation is well founded ; 
for I have always remarked, that they 
procure an abatement of the pain fooner 
where thefe vefications have already ap- 
peared, than when they are employed fp 
early as to prevent them from rifing, 
which they frequently do when they are 
applied immediately after a burn is iu- 
flided. 

Whatever remedy we employ, it ought 
to be perfifted in as long as the pain con- 
tinues ; and in extenfive burns, where 
the irritation is great, along with exters- 
nal applications, opium Uipuld be prefcri- 

Vql. V. A a ht^ 



362 Of Burns. Ch. XXXVII 

bed in dofes adequate to the degree of 
pain. Even that (lupor with which pa- 
tients in this ficuation are fometimes at- 
tacked, is more readily removed by opi- 
um than by any other remedy. As this 
fymptom is probably induced by fome 
degree of effufion upon the brain, and as 
we are to confider this as an effeifl of 
the irritation which always accompanies 
burns, we may readily conceive that opi- 
ates fhould prove particularly ufeful in 
removing it : And I have found in a 
variety of inftances that they do fo. 

With refpedl to the management of 
the vefications ; by fome we are advifed 
to open them immediately, while others 
aflert that they fhould never be meddled 
with. In judging from my own ob- 
fervation, I would fay that they fhould 
never be opened till the pain arifing 
from the burn is entirely gone : for du- 
ring this period, the lead accefs of air is 
attended with a great deal of uneafinefs. 
But when the irritation produced by the 
biara is fubfided, they may be opened with 

fafety ;, 



Ch. XXXVII. Of Burns. 3^5 

fafety : and at this period It ought al- 
ways to be done ; for wlien the ferum is 
allowed to reft long upon the jfkin be- 
neath, it is apt to render it tender, and 
even to induce fome degree of ulceration, 
which might with eafe be prevented. 
Even at this time the veficles fhould be 
opened with fmall punflures, inftead of 
large incifions, fo that as little air may 
be admitted as poifible. And after the 
ferum is difcharged, the beft application 
that can be mafde to the part, is a thia 
liniment of wax and oil, with a fmall pro- 
portion of Saccharum Saturni. Oil by 
itfelf is too thin, as it runs quickly off; 
and ointments of the ufual confiftencc 
give more pain than a liniment, as their 
ftiffnefs prevents them either from be-- 
ing applied or removed fo eafily. 

In this mariner all fuch burns as we arc 
now treating of, may in general be cu- 
red, excepting where they are fo exten- 
five as, by the irritation which they pro- 
duce, to excite much inflammation and 
fever. In fuch circumftances, blood- 
A a 2 letting, 



364 Of Burns, Ch. XXXVII. 

letting, and other remedies adapted tothe 
particular fymptoms, mufi: be advifed ; 
and when the injured part is found to 
ulcerate, vvhicli will often happen in fe- 
■vere burns, even where the fkin remain- 
ed entire for feveral days, thofe remedies 
mud be employed which the nature of 
the fci'e may appear to render neceflaryj^ 
and for wiiich we mofl refer to the dif- 
ferent fe<ftions of a former publica- 
tion *. 

When, again, burns are from the firft 
attended wirh lofs of fubflance, asufually 
happens when they are produced by the 
application of hot metallic bodies, cool- 
ing emollient applications prove moft ef- 
feflual, the part being kept conftantly 
moid with a liniment compofed of equal 
parts of lime-water and lintfeed-oil often 
gives immediate eafe ; and the eafieft 
way of applying it is, to daub the parts 
frequently over with a foft pencil well 
foaked in it. The application and remo- 
val even of the foftelt coverings is often 

"* Vide Treatife on Ulcers, &c. 



Ch. XXXVir. Of Burns. 365 

pjoduv-^liive of much pain ; and I have al- 
ways found in burns of this kind, that 
their being expofed to the air does not for 
the firfl: two or three days do any harm : 
On the contrary, it often gives relief 
when no advantage is derived from any 
application. But as foon as the pain and 
irritation produced by the burn are re- 
moved, the parts fhould be covered and 
treated in the fame manner as ulcers 
proceeding from any other caufe. The 
liniment I have mentioned of lime water 
and lintfeed oil, is perhaps the bed ap- 
plication that has yet been employed in. 
burns of this kind. In fome cafes, how- 
ever, T have found that more immediate 
eafe has been procured from the applica- 
tion of Goulard's Cerate ; or the \j\\^ 
guentum Nutritum ; and a weak folution 
of Saccharum Saturni hasfonietimes pro- 
ved fuccefsful. 

In burns arifing from the explofion of 

gun-powder, fome of the grains of the 

powder are apt to be forced into the 

cutis. At firft they produce mucli irri- 

A a 3 tation ; 



S66 ' Of Burns. Ch. XXXVII. 

tation ; and if they be not removed, they 
commonly leave marks, which afterward8 
continue fixed and permanent. They 
fhould therefore be picked out with the 
point of a needle, or any other fmall in- 
ftrument, as foon as poflible after the ac- 
cident ; and with a view to prevent inflam- 
mation, as well as to diffolve and carry 
off any particles of the powder which 
might remain, the parts affedled fliould 
be kept covered for a day or two with 
emollient poultices. In other refpeds, 
injuries of this kind are to be treated in a 
iimilar manner with -burns produced in 
any other way. 

When parts which lie contiguous are 
burnt, they are apt to adhere to each o- 
ther, if fome pains be not taken to pre- 
vent them. This is more particularly 
the cafe with the fingers and toes, and 
with the noftrils and palpebrae. The fu- 
reft method of preventing it, is to keep 
pledgits covered with any proper dreffings 
inferced between them during the courfe 
^f the cure. 



Ch. XXXVIf. Of Burns. 2>^y 

In the treatment t)f ulcers arlfmg from 
burns, it is proper to remark, that the 
parts are very apt to become foft and 
fungous, and to rife confiderably above 
their natural level. When this is ob- 
ferved, any emoUient applications that 
may have been previoufly ufed Ihould 
be laid alide : fuch as are moderately 
aflringent Ihould be employed inftead of 
them; .,nd gentle comprelTion with a 
roller proves particularly uleful. Bath- 
ing the pares with a common faturnine 
walh, or with lime-water, or a folu- 
tion of aham, often proves ferviceable ; 
and one of the beft ointments for this 
purpofe is the common Ceratum e La- 
<pide Calaminare. By perfirting ia thefe 
means, any fungous excrefcences of this 
kind will, for the mod part, be foon re- 
moved ; but when they prove obftinare, 
they mull be taken down by the applica- 
tion of burnt alum, blue vitriol, or lunar 
^iCauftic. 

Aa4 chap; 



Of Tumon, Ch. XXXVIlL 



CHAP. XXXVIII. 
Of Tumors. 



SECTION J. 

Of Tumors in general. 

EVERY prafeternatural enlargement, 
in whatever part of the body it i^ 
feated, may be termed a Tumor. 

Tumors daily occur in one form or 
Another : They are often followed with 
important cpnfequences ^ they frequently 
give much embarraffment both to patients 
and furgeons : Fof thefe reafons they me- 
rit particular attention. 

Jduch 



^eOi. I. in generat. 369 

Much variety occurs in the general 
appearances of tumors, as well as in the 
method of treatment beft fuited for their 
removal : But fuch varieties only fliould 
be mentioned in a work of this kind as 
require fome peculiarity ii\ the method of 
cure. 

' Tumors may with propriety be divi- 
ded into two general clafles : Into fucli 
as are of an acute or inflammatory na- 
ture ; and fuch as are chronic or indo- 
lent. Authors have for the moft part 
diflinguithed them into fuch as are faid 
to be of a warm nature ; and thofe 
which they fuppofe to be cold, from 
their being deftitute of pain and rednefs, 
fymproms which we comnionly obferve 
to accompany heat. But the terms wc 
have mentioned of Acute or Inflamma- 
tory, and Chronic or Indolent, are more 
fcientific ; at the fame time that they 
are more expreflive of thp real nature of 
the different affedlions : for it will be 
found to hold perhaps univerfally, thac 
itnraors are acute or indolent, that is, 

thac 



370 Of Tumors. Ch. XXXVIII. 

that they are rapid or flow in their pro- 
grefs, nearly in proportion to the degree 

of inflammation with which they are at- 
tended. 1 mean therefore to rank in 
the firfl: dafs of tumors, all fuch as from 
their commerttement are accompanied 
with inflammation ; and in the fecond, 
all thofe which are not evidently accom- 
panied with this fymptom. 

It will unavoidably happen, however, 
that fome tumors will be mentioned un- 
der one clafs, which, during fome part 
of their progrefs, may appear to belong 
to the other : Thus, a tumor beginning 
from fome inflammatory affedion, may 
terminate in a flate of perfed indolence ; 
while others, which at iirfl: were evident- 
ly chronic or indolent, may at laft be- 
come highly inflammatory. We fliall 
endeavour, however, to charaderize them 
by thofe fymptoms which appear mofl: ob- 
vioufly at their commencement : A mode 
of diftindion which appears to be the 
moft accurate ; for it is not what a tu- 
mor may eventually become, but what 

it 



Sed. I. in general* 371 

it adually is on its firft: appearance, that 
can admit of any defcription. 



Class I. Acute or Inflammatory Tumors'. 

Phlegmon, with its confequences, abfcefs 

and mortification. 
Eryfipelas. 
Ophthalmia. 

Inflammation of the ear. 
Angina, or inflammation of the throat. 
Inflammation and abfcefs of the liver. 

of the breafls of women, 

of the teftes. 

of the anus and perinaeum. 
Venereal buboes. 
Lumbar abfcefles. 
Paronychia or whitloe. 
Chilblains. 
Sprains and contufions. 



Class 



37^ Of Tumors Ch. XXXVIII. 



Class II. Chronic or Indolent Tumors. 

E^cyfled tumors, ufually fo termed. 
Ganglions. 

Swellings of the burfae mucofae. 
Concretions and praEternatural excre- 
fcences within the capfular ligaments 
of joints. 
Aneurifms, 

The true, the falfe, and varicofe aneu- 
rifms. 
Varicofe veins. 
Hemorrhoidal fwellings. 
Hydropic fwellings. 

anafarca or oedema. 

hydrocephalus. 

hydrops peftoris, and 
hydrops pericardii, 

afcites. 

dropfy of the ovaria. 

hydrocele. 

fpina bifida. 

Swellings in the fublingual glands. 

Tumors containing air. 

Gene- 



Sea. I. in general. Z7% 

General emphyfema produced by air 
efcaping from the lungs into the cel- 
lular fubftance, as lometimes happens 
from the fpiculse of fradured ribs pe- 
netrating the fubftance of the lungs. 
Local emphyfematous tumors produced 
by putrefadlion in a particular part. 
This is a rare occurrence ; but cafes 
of it are recorded by diflFerent authors. 
Tympanitis. 
Tumors formed by the difplacemenc of 

particular parts, 
HernicE ; 

of the brain, 

inguinal and fcrotal. 

congenital. 

crural. 

umbilical. 

ventral. 

at the foramen ovale. 

in the perinseum, 

of the alimentary canal and me- 

fentery. 
of the omentum; 

Hernise 



374 Of Tumors Ch. XXXVIII. 

Hernix of the liver, fpleen, and other 
abdominal vifcera. 
of the bladder. 

of the inteftines in the vagina. 
Protrufion of the eye-ball. 
Prolapfus uteri. 
Prolapfus ani. 
Tumors formed by the difplacement of 

bones in cafes of diflocation, 
Scrophulous tumors. 
Bronchocele. 
Sarcomatous tumors. 
Sarcocele. 
Scirrhus. 
Cancer. 
Polypous excrefcences in the nofe and 

throat. 
Polypi in the ear. 

in the uterus. 
Condylomatous tumors in the anus. 
Excrefcences in the urethra. 
Naevi materni. 
Warts. 
Corns. 
Tumors from afFedions of the bones. 

Simple 



Seft. I. in zeneral. ■ 375 

Simple exoflofes. 
Venereal nodes. 
Spina ventofa, 

"We lliall now proceed to confider fuch 
of thefe tunnors as h^ive not yet been de- 
fcribed, or chat will not more properly 
fall to be mentioned in fome other chap- 
ter. Of thefe lart, indeed, all that oc- 
cur are fuch as are produced by the 
heads of bones when difplaced, which 
will be confidered when we come to the 
Chapter on Diilocations. 



S E C T I O N IT. 



Of Acute or Inflammatory Tumors, 



THE general theory and management 
of inflammation and its confequen- 
ces, have already been fully treated of * : 

We 

« Fide Treatife on Ulcers, &c. Part I. 



37^ Of Jcute or Ch. XXXVIII. 

We mufl therefore refer for this part of 
our fubjedl to what was then (aid upon 
it : and in confidering thofe varieties of 
tumors in which inflammation takes 
place, fuch circumftances only will be 
taken notice of as from peculiarity of 
iituation, or fome other caufe, require a 
particular treatment. 

In the Treatife on Ulcers, eryfipelas 
was mentioned and defcribed as a varie- 
ty of inflammation : but as phlegmon, 
with its confequences, was the only fub- 
jedl Vi^hich we then meant to difcufs, the 
treatment of eryfipelas was not confider- 
ed ; we fliall now therefore offer a few 
obfervations upon it. 



% I' Of Eryjtpelas. 

In phlegmon, the inflammation is cir- 
cumfcribed. In general, it is deeply 
feated in the cellular fubftance ; and 
any efl^ufion which takes place is for the 
moit part converted into purulent matter : 

But 



Se£t. II. Infiaimnatory Tumors. 377 

But in eryfipelas, the tumor is diiFufed, 
and not much elevated ; it feldom pro- 
ceeds deeper than the fkin ; and any ef- 
fufion with which it is attended is com- 
monly thin and acrid, and is not conver- 
tible into pus. 

By experience we know, that fores 
proceeding from eryfipelas are in gene- 
ral difficult to cure: It fhould therefore 
be our fird objecl: to endeavour to pre- 
vent that effufion of which thefe lores 
are the confequences. By fome it is al- 
ledged,that this pradice niufl be attended 
with rifk, as eryfipelas in general ap- 
pears to proceed from a conflitutional 
affedion ; and hence we are advifcd ra- 
ther to encourage the difcharge of that 
matter which nature feems inclined to 
depofite. This obfervation, however, 
does not appear to be u^ell founded ; for 
it is found that the difcuifion of erydpe- 
latous affedions may be attempted with 
tlie fame freedom and fafety as inflam- 
mation of any other kind. 

There is a common prejudice againft 
Vol. V. B b the 



378 Of Acute or Ch. XXXVIII. 

the ufe of un(n:uous applications, and 
whatever contahis moillure, in every 
c^fe of eryfipelas ; and fine flour, ftarch, 
or hair-powder, are almoft the only re- 
medies employed externally. Thefe are 
ufed with a view to abforb the acrid 
matter, which affe^^ions of this kind of- 
ten throw out in the form of puftules, 
and which und:uous and moifl: applica- 
tions are rather fuppofed to encourage. 
But to me it appears that they prove 
more nfeful in preventing the effufion or 
formation of that matter, than in abforb- 
ing it afterwards. By foothing or allay- 
ing that uneafy fenfation which ufually 
accompanies eryfipelas, and which they 
often do very effedlually, they necefla- 
rily tend to lefTen that preternatural ex- 
ertion of the affeded veffels, which in 
every cafe of inflammation we confider 
as the caiife of the fubfequent effufion ; 
and as they ufually prove more pleafant 
in every refpecl than moift applications, 
they (hould therefore in the firfl: ftages 
of the diforder be preferred. It hap- 
pens 



Se.d:. II. Inflammatory Tumors. 379 

pens indeed, in fome cafes, that tbey have 
little or perhaps no efFedl in procuring 
relief. In fuch inftances, I have fome- 
times found, that by keeping the infla- 
med part expofed to the air, and wetting 
k every now and then with a feather 
foaked in a weak folution of faccharum 
Saturni, immediate eafe has been procu- 
red, and no difadvantage has afterwards 
occurred from it. In general^ however, 
the dry farinaceous powders anfwer bet- 
ter. 

Almofl an univerfal prejudice has pre- 
vailed againft blood-letting and other 
evacuations in eryfipelas. And as it is 
commonly fuppofed to be attended with 
fome degree of putrefcency, inftead of 
evacuations, bark, wine, and warm fti- 
mulating cordials, have been recom- 
mended. It appears, however, that the 
ideas of praiflitioners upon this point 
have not been founded on obfervation : 
for it is now known, that in every cafe 
of eryfipelas, blood may to a certain ex- 
tent be evacuated with fafety ; and J)y 
B b 2 doins: 



380 Of Acute or Ch. XXXVIII. 

doing lb, and adhering in every refpefl 
to an andphlogiftic regimen, we will in 
general be almofl certain of preventing 
the difeafe from terminating in thofe ef- 
fufions which we have mentioned, and 
which at all times we fliould endeavour 
to prevent. 

It is proper, however, to remark, that 
local blood-lettiosr, which in other va- 
rieties of inflammation proves highly 
iifeful, is not here admiffible : lor the 
orifices by which it mufi: be drawn off 
are very apt to degenerate into thofe 
troublefome ulcers which eryfipelas, 
when it terminates in efFufion, is very apt 
to produce. 

By one or more general blood-lettings, 
according to the ftrength of the patient ; 
by the ufe of gentle laxatives, mild fu- 
dorifics, and a cooling diet ; and bj'- fre- 
quently dufling the part afFedfed with 
one or other of the powders w^e have 
mentioned, almofl every eryfipelatous 
tumor may be difcufTed : But when ef- 
fuflon-is found to have occurred in any 

con- 



Sed. II. Inflammatory Tumors. 381 

confiderable quantity, it (hould be dif- 
charged immediately by a fmall opening 
in the mod depending part of it. In 
this ftate of the difeafe, emollient cata- 
plafms are commonly applied, with a 
view to bring the contents of the fwell- 
ing to fuppuration. This, however, 
proves always pernicious : for the effufioii 
being of a nature which camiot be con- 
verted into pus, poultices can never be 
of the fame ufe as in cafes of phlegmon ; 
and as it is commonly fharp and acrid, 
it is apt to do mifchief, by corroding the 
fldn and other contiguous parts, when it 
is allowed to remain. The bed applica- 
tion in this (late of the difeafe, is any of 
the faturnine ointments, fuch as Gou- 
lard's cerate, or the common wax oint- 
ment, with a fmall proportion of Saccha- 
rum Sacurni. 



B b 3 § 2. 



v?,. 



3S2 Of Acute of Ch, XXXVIlt- 



% 2. Of hfammation of the Ear. 

The paiTage, as \vell as the bottom of 
the ear, are entirely membranous j con- 
fequently the inflammation which at- 
tacks them proves very painful : for we 
know that ipftamfflation of membranous 
parts gives more pain than that of parts 
6faloofer texture; as the blood-veiTels 
in the former do not yield ilo readily as 
thofe of the latter, to the diftention 
whicli always accompanies inflamma- 
tion. 

The remedies to be employed in cafes 
of this kind fhould be regulated by the 
ftage of the difeafe. When the inflam- 
mation has fubfifled fo long as to give 
reafon to fufped that it will terminate 
in fuppuration, which it is apt to do ve- 
ry quickly, emollient applications prove 
mdft ufeful : the ear fllould be frequently 
fomented with warm emollient fleams ; 
and it often proves ferviceable to cover 

the 



Sed. II. Inflammatory Tumors. 383 

the affeded fide of the head with large 
emollient poultices. But in the com- 
mencement of the afFe(5lion, we fiiould in 
general attempt to prevent fuppuration : 
for it is often difficult to obviate the ef- 
feds of it when matter is once formed in 
the ear ; and a long continued difcharge 
is frequently produdive of deafnefs. 
With this view, nothing proves in gene- 
ral fo efFe(5lual as the application of a 
fmall blifter behind the ear : and by 
pouring a few drops of laudanum into 
the palFage, or of compound fpirit of la- 
vender mixed with a fmall proportion of 
oil, we very commonly have it in our 
power to remove or abate the pain ; and 
the irritation being in this manner re- 
moved, the rifk of fuppuration enfning 
is thereby much leflened* 

Our endeavours, however, for this 
purpofe will often prove abortive : In 
which event, and when it is evident that 
matter is formed, we fliould endeavour 
to bring it off' as freely as poflible, by 
bathing the ear in warm water, and even 
B b 4 by 



384 Of Acute or Ch. XXXVIII. 

by injecfting a little warm water into it. 
By thefe means we may often put a flop 
to the difcharge : but when it ftill con- 
tinues to flow, aflrlngent injedions, of 
lime-water, or of mild faturnine folu- 
tions lliould be employed ; which feldom 
fail when the difeafe is folely confined to 
the foft parts of the ear. When the 
bones of the ear are affedled, which in 
general may be known by the matter ha- 
ving a very offeniive fmell, and being of 
a black or dark brown colour, all that 
art can do, is to keep the paflage clear 
by the ufe of injedlions. The cure in 
thefe cafes mud be left to the operation of 
nature. 



§ 3- Q/" Angina. 

Every inflammatory affedlion of the 
throat is termed Angina, or Squinzy. 

As abfcefles in thefe parts prove al- 
ways troublefome, and in fome cafes 
dangerous, we fhould endeavour to cure 

every 



Se6t. II. Inflammatory Tumors. 385 

every inflammation with which they are 
attacked by refolution. 

With this view^, one or more general 
blood-lettings fliould be prefcribed, ac- 
cording to the ftrength of the patient. 
Smart purgatives prove particularly ufe- 
ful ; and fome advantage is often derived 
from diaphoretics. 

None of thefe remedies, however, can 
be depended on with fuch certainty as 
the local difcharge of blood from the 
part affedled, and the application of a 
blifter to that part of the neck which 
lies mod contiguous to it. In Plate LIU. 
figs. I', and 3. inftruments are delineated 
for the purpofe of drawing blood from the 
throat by means of fcarifications ; and 
when they are employed with freedom on 
the firft appearance cf inflammation, it 
will feldom terminate in fuppuration. Fo- 
menting the throat with fleams of warm 
vinegar proves fometimes ufeful ; and 
confiderable advantage has been derived 
in different inftances fiom aftringent 
gargles, of infufions of oak-bark, of red- 

rofe 



38S Of Acute or Ch. XXXVIII. 

role leaves with a proportion of alum or 
of the vitriolic acid, and of Saccharum 
Saturni dilToIved in water. A general 
prejudice prevails againfl: the ufe of any 
of the faturnine applications in the form 
of gargles, from their being fuppofed to 
be of a poifonous nature. But although 
I have often ufed them, I never knew an 
inflance of any harm occurring from 
them ; and they have frequently proved 
highly ferviceable. In fmall quantities 
I believe they might be fwallowed 
with fafety ; but we all know that 
gargles may be employed without any 
part of the liquor being allowed to got 
over. 

It will often happen, however, that 
thefe and all other remedies will fail, 
cither from the application of them being 
too long delayed, or from the violence 
of the inflammation. When fuppuration 
is evidently to take place, it ought to be 
promoted by the external application of 
warm poultices to the throat, and by the 
patient being made to infpire the warm 

fleams 



i§e£b. II. Inflammatory Tumors. 387 

fleams of milk, or of any emollient de- 
codTion, by means of the machine deli- 
neated in Plate LIII. fig. 2. When mat- 
ter is fully formed, it fliould be difchar- 
gedby an opening made into it with one 
of the inftruments mentioned above for 
fcarifying the throat. 



§ 4. Inflamfnation and Abfcefs of the Lher. 

The fubftance of the liver being fofc 
and yielding, .we would not a priori ima- 
gine that it would be liable to inflame. 
We find, however, that in warm climates, 
particularly in the Eaft Indies, this viH. 
cus becomes more frequently inflamed 
than perhaps any other part of the body; 
probably from the bile in thefe climates 
being apt to become fo acrid as to excite 
irritation in the parts to which it is ap- 
plied. In fome cafes too, inflammation 
occurs in the liver frorti external vio- 
lence. 

Inflammation of this part is attended 

with 



383 Of Acute or Ch. XXXVIII. 

with a dull uneafy fenfation over all the 
region of the liver, with cholic pains and 
llcknefs at ftomach ; the patient is liable 
to frequent cold and hot fits : and for the 
mod part, the colour of his fkin, as well 
as his urine, is tinged yellow. 

When fuppuration takes place, and 
efpecially when the abfcefs is large, the 
patient complains of pain extending up 
the right fide to the top of the flioulder. 
In fome cafes this fymptom occurs even 
in the inflammatory flate of the difor- 
der ; but it happens more frequently af- 
ter the formation of matter, probably 
from the weight of the abfcefs adlng up- 
on the diaphragm and pleura, with which 
the liver is connetT:ed, The region of 
the liver becomes daily more tenfe ; and 
if the convex part of it be chiefly affect- 
ed, a fbftnefs, and even a fluftuation of 
matter, is often difcovered through the 
teguments of the abdomen. 

In the commencement of this affec- 
tion, the fame remedies which are ufeful 
in other cafes of local inflammation 

prove 



Sed. II. Inflanwiatory Tumors. 389 

prove mofl: fuccefsful. Blood-letting 
fhould be immediately prefcribed ; the 
quantity to be determined by the ftrength 
of the patient : but inftead of taking it 
from a vein, it fliould be drawn oflP by 
cupping and fcarifying the part afFe(5led. 
When the fcarifications are made of a 
fufficient depth, almoft any quantity of 
blood may be got in this manner ; and 
no remedy with which we are acquainted 
proves fo efFe6lual in removing the inflam- 
mation. Bliftering the pained part is alfo 
frequently of fervice ; the bowels fliould 
be kept moderately open with mild laxa- 
tives ; and a gentle perfpiration fljould be 
encouraged over the whole furface of the 
body. 

In general, this treatment will prove 
fuccefsful when it has been employed 
early in the difeafe ; but when the fymp- 
toms do not foon yield, mercurials ihould 
be advifed without any farther delay : 
for in the removal of inflammatory af- 
fedions of the liver, nothing has hither- 
to proved fo efFedlual as mercury in one 

form 



39© Of Acute or Ch. XXXVUI. 

form or another. The common mercu- 
rial pill of the Edinburgh Difpenfatory 
anfwers as well as any other ; and it 
feems to ad: with more certainty when 
conjoined with fmall dofes of opium. 
Fridions with mercurial ointment upon 
the part affedled, are fometimes employ- 
ed with advantage : But whatever form 
of the medicine be ufed, it fhould be 
quickly carried fo far as to affedl the 
mouth, which fhould be kept moderately 
fore for feveral weeks, unlefs the difeafe 
fubfides immediately ; in which cafe a 
fliorter courfe will anfwer the purpofe. 

As it is of much importance in every 
cafe of this kind to give a free difcharge 
to the bile, if the patient does not other- 
wife get regular and eafy pafTage of his 
bowels, he fhould, during the mercurial 
courfe, have a gentle faline purgative 
every third or fourth day, by which the 
difcuffion of the inflammation is often 
much promoted. 

Suppuration, however, will often take 
place, notwithftanding all that can be 

done 



Sed. II. Inflammatory Tumors. 391 

done to prevent it ; and when it is 
known, or even fufpedted to have hap- 
pened, an incifioH Qiould be made into 
the abfcefs to difcharge the matter. When 
the abfcefs is feated on the convex or pro- 
minent part of the liver, and when the 
quantity of matter contained in it is con- 
iiderable, we will readily difcover in by 
the touch ; and in this cafe there is no 
room to hefitate. But even where we 
have not this circiimflance for our direc- 
tion, a little attention will oAen enable 
us to difcover almoft with certainty whe- 
ther fuppuration has occurred or not. If 
along with the pain in j:he right fliouidcr 
and neck, which we have mentioned, it 
js obferved that the region of the liver 
is more bulky than it was before, and 
that the teguments which cover it are 
become foft and oedematous ; and efpe- 
cially if the patient complains of fre- 
quent (liivering fits, a fymptoni which 
very conftantly accompanies internal 
fuppuration ; we may conclude widi 
piuch certainty that matter is formed. 

la 



392 Of Acute or Ch. XXXVlll. 

Ill every fituation, matter fliould be 
difcharged, perhaps as foon as it is known 
that complete maturation has taken place. 
But abfcefles feated in any of the lar- 
ger cavities, efpecially where they lie fo 
deep as the liver or any other of the vif- 
cera, fliould be opened even before there 
is reafon to fuppofe that all the effufed 
fluids are {o completely converted into 
pus as we might othe rwife wiQi to be the 
cafe : Indeed this Qiould be confidered 
as an eftaUlilhed maxim in pradice ; for 
the chance of thefe colledions burfling 
inwardly is much greater than of their 
burfting outwardly, where the teguments 
■which cover them are thick and ftrong, 
when compared with the peritonseum, 
the only membrane which lies between 
them and the inteftines. AbfcefTes of the 
liver have been known to burll thro' the 
diaphragm, fo as to be emptied into the 
thorax: in a few cafes the matter has been 
carried into the duodenum by the com- 
mon palTage of the bile ; and fometimes, 
by the great arch of the colon adhering 

to 



Se6):. II. hiflarnmatory Tumors. 393 

to the liver, a communication has been, 
formed between them ; by which the 
matter of abfcefles in this fituation has 
been very completely evacuated : but for 
the mod part, when it is not difcharged 
by an external opening, the abfcefs burfts 
into the cavity of the abdomen. 

With a view to prevent fuch a fatal 
occurrence, the alfi fiance of furgery 
fliould be immediately called in as foon 
as the appearances and fymptoms we 
have mentioned give caufe to fufpe(5l that 
matter is colledled : An incifion of a fuffi- 
cient length fhould be made with a fcalpel 
through the external teguments in the 
moft depending part of the tumor j and 
on reaching the abfcefs, it may either be 
opened with the point of the fcalpel or 
with a lancet ; but piercing it with a trocar 
is preferable, as in this manner we have 
it in our power to evacuate the matter 
llowly and gradually, which in large 
colledions is a point of importance, and 
therefore requires attention. Even this 
opening into the abfcefs, however, fliould 

Vol. V. Cc be 



394 Of Acute or Ch. XXXVIII. 

be afterwards enlarged, otherwife there 
would be lome rifk of its clofing before 
the cyft containing the matter collapfes 
fufficiently for the prevention of farther 
colledions. This being done, a pledgit 
of foft lint covered with any emollient 
ointment, or merely dipped in oil, fliould 
be gently infinuated to a fufEcient depth 
between the lips of the wound, to pre>- 
vent them from uniting till the abfcefs 
collapfes and fills up from the bottom : 
a procefs that will be much haftened by 
a proper application of prefTure upon the 
tumefied parts, by means of a flannel 
roller paffed two or three times round 
the body. 

When the vacuity produced by the dif- 
charge of matter does not foon fill up, it 
will be proper to introduce a canula to 
preferve a free pafTage for any matter that 
may afterwards form. But this precau- 
tion is feldom neceflary ; for abfcefTes in 
the liver heal fooner, and with fewer in- 
conveniences, than fimilar affedlions in 
perhaps any other part of the body. In- 
deed 



Seel. 11. Inflammatory Tumors. 395 

deed this Is fo well afcertained, that I 
would advife an opening to be made into 
the abfcefs in every inftance where there 
is the leatt caufe to fufpedt that matter 
has formed in the liver. Many prac- 
titioners indeed aflert, that no attempt 
of this kind is admiffible unlefs the ab- 
fcefs be feated In the convex part of the 
liver. It muft be allowed, that abfcefTes 
in this fituaiion are much more accef- 
fible than fuch as are feated in the con- 
cave part of it. But wherever they are 
fitiiated,'a proper vent fliould be procu- 
red for the matter ; for if it be not eva- 
cuated by an external opening, we may 
conclude almofl: with certainty, that it 
will be emptied into the abdomen, by 
which the patient will inevitably die. 

In all affedlions of the liver that occur 
in warm climates, the bark is commonly 
employed on the firfl; appearance of any 
of the fymptoms: The putrefcent ten- 
dency of the bile is the oftenfible reafon 
of this. But I believe it will be found 
that no dependence Ihould be placed 
C c 2 uppn 



J> 



56 Of Acute or Ch. XXXVIIL 



upon the bark during the firft or inflam- 
matory flage of this difeafe. In this pe- 
riod of the diforder it niay even do mif- 
chief; but when fuppuration has taken 
pUce, and when the matter is difcharged 
from the abfcefs, bark will prove equally 
ufeful, as it is found to do in fimilar af- 
fedlions of other parts of the body. 

When, by too long delay, it unfortu- 
nately happens that an abfcefs either 
burfts into the cavity of the cheft or in- 
to the abdomen, the matter (hould be 
drawn off immediately ; in the one cafe, 
by the operation of the empyema, defcri- 
bed in Chapter XXII. ; and in the other, 
by the common operation of the para- 
ce/itefis, Chapter XXI. 



% S- ^f Inflammation and Abfcefes in ihe Breajis 
of Wotnen^ 

The breads of women are liable to be 
a^cd upon by every caule which excites 
inflammation in other parts of the body : 
But affections of this kind occur moft 

frc. 



Sed. II. Inflammatory Tumors* 397 

frequently in nurfes by the gorging or 
ftoppage of the milk, which almoft con- 
ftantly takes place from fudden or im- 
prudent expofure to cold : The bread be- 
comes ftiff, fwelled, and painful; the milk 
runs off in fmall quantities, but not fo as 
to afford any effe(!:tual relief; a*nd the pa- 
tient grows hot and reftlefs, while much 
third prevails, along with a full quick 
pulfe. Prsflitioners are divided with re- 
fpedt to the method of treating cafes of 
this kind : By fome it Is fald, that difcuf- 
flon of the tumor fhould always be at- 
tempted; while others affert, thatwhen this 
does not fucceed, it often does mifchlef, 
by inducing fclrrhous affe(fHons, which, 
cannot afterwards be dllTolved, and which 
are apt to terminate in cancer. 

So far as I can judge from my own 
oblervatlon, there Is no ropm to hefitate. 
Our pra(flice in inflamed breads fliould 
be the fame as In every cale of inflamma- 
tion, wherever It may be feated. In the 
fird dages of the diforder, difcudion of 
the tumor fliould be always attempted ; 
C c 3 while 



395? Of Acute or Ch. XXXVIII. 

while it would be in vain, and higlily uti- 
proper, to advife it when the fwelling has 
been of fuch duration as to have any 
tendency to fuppurate. The rifk of our 
inducing fcirrhus by this practice, feems 
to be in a great meafure imaginary : It 
rather appears, indeed, that cancer is 
more apt to occur from the improper 
management ot thofe fores which enfue 
from collections of matter in the mam- 
tna, than from any means that can be 
ufed to prevent the matter forming. We 
are farther induced to follow the prac- 
tice, from the great diftrefs which al- 
ways attends fuppuration in the mamma : 
Indeed, the pain and mifery of the pa- 
tient is in fuch cafes often fo great, that 
no doubt can remain with unprejudiced 
practitioners of the propriety of endea- 
vouring in every cafe to prevent it. 

It is fcarcely neceflary to remark, that 
the fame remedies prove ufeful here that 
fucceed in the difcuffion of inflammation 
in other parts : But it is truly furprifing, 
that there fhould be almofl an uniyerfal 

ore? 



Se£t. ir. Inflammatory lumors. 399- 

prejudice in every inflamed bread againft 
the mod powerful of all difcutients, 
blood-letting. Afraid of this evacuation 
tending to diminifli the quantity of milk, 
we avoid it entirely. In this, however, 
I am convinced we are wrong. In 
every cafe of this kind I have been in 
the pradlice of bleeding freely. It has 
not appeared to diminifli the flow of 
milk; while its efleds in preventing 
fuppuration are very great. The quan- 
tity of blood to be taken away, mufl: al- 
ways be determined by the violence of 
the inflammation, and by the ftrength of 
the patient: But, in general, the prac- 
tice will be more effedlual, when as much 
as the patient can eafily bear to lofe is 
taken at once, than when the fame, or 
even a greater quantity, is taken at dif- 
ferent times. Purgatives prove parti- 
cularly ufeful ; and a cooling diet is 
equally neceflary here as in any other 
cafe of inflammation. 

As nothing tends more to prevent the 

difcuflion of inflamed tumors than pain, 

C c 4 ng^ 



400 Of Acute or Ch. XXXVIII. 

nothing fhould be omitted that can in 
any degree alleviate this fymptom : And 
as no remedy with which we are ac- 
quainted, proves fo effedlual in removing 
it as opium, it ihould always be given in 
fuch dofes as are found to be fufBcient. 
"With a view to remove the tenfion of the 
breaft, it fhould be gently rubbed over 
with althea ointment, or even with oil ; 
but the external applications which are 
moft to be trufted are thofe of a cooling 
aflringent nature ; fuch as a folution of 
fal ammoniac in vinegar and water ; fpi- 
ritus Mindereri ; and all the faturnine 
applications. Cloths dipped in any of 
thefe fliould be kept conilantly applied to 
the breafl: ; by which, and by attention 
to the reft of the treatment advifed above, 
almoft every tumor of this kind will be 
removed, unlefs the inflammation has 
been of long continuance before the re- 
medies are employed ; in which cafe, if 
the pain and tenfion are confiderable, it 
■will always be more advifable to endea- 
trouf to bring the tumor to fuppurate, 

than 



SeS:. II. Inflammatory Tumors. 401 

than to attempt any other method of 
cure. For this purpofe, we rely with moft 
certainty on a frequent renewal of warm 
fomentations and poultices ; and when 
matter appears to be fully formed, it 
lliould be difcharged by an / opening 
made in the mofl: depending part of the 
colledlion ; At lead an opening ftiould 
always be advifed, when it is found that 
the matter is pointing at an improper 
ipart where it would not find a free 
vent. 

In the treatment of thofe cafes of tu- 
mefied inflamed breafts, which occur in 
nurfing, it is a doubt with many pradli- 
tioners, whether the milk fhould be 
drawn off or not. Indeed many afTert, 
that drawing it off, either by continuing 
the child or with glaffes, does mifchief ; 
and therefore they advife it not to be at- 
tempted. I have never obferved, how- 
ever, that any inconvenience enfued from 
it ; and as it always procures relief, I 
advife it in every inftance. When the 
breaft is much fwelled, the nipple cannot 

be 



402" Of Acute or Ch. XXXVIII. 

be laid hold of by the child : In fuch 
cafes the glaffes reprefented in Place 
LXV. may be ufed with advantage. 

^ 6. Of Inflammation of the Teftes, 

Inflammation of the teftes may be 
induced in various ways : By the appli- 
cation of cold ; by external violence ; 
and by every other caufe that tends to 
excite inflammation in other parts of the 
body. But the moft frequent caufe of 
it is a gonorrhoea virulenta. The com- 
mon opinion refpecfling this was, that it 
occurred from the matter in gonorrhoea 
falling down, as it was termed, upon the 
teftes : And this appeared the more pro- 
bable from its being obferved that the 
teftes were apt to fwell upon the dif- 
charge being flopped, at the fame time 
that the afi'edlion of the teftes was com- 
monly relieved by a return of the run- 
ning. 

It is now known, however, that no 

com- 



Sect. II. Inflammatory Tumors. 403 

communication fubfifts between the ure- 
thra and teftes by which matter can be 
conveyed from the one to the other : 
And the mofl probable opinion is, that 
in the fwelled teftes occurruig from go- 
norrhoea, the inflammation is commu- 
nicated from the urethra, and fpreads a- 
long the vafa deferentia to the teftes. 

A fudden ftop being put to the dif- 
charge, whether by the ufe of irritating 
injedlions or by any other caufe, is very 
commonly attended with an increafed 
degree of inflammation ; to abate which, 
nothing proves more efFeLtual than a re- 
turn of the running. In this way we 
account more clearly than in any other 
manner for the effedl produced upon the 
teftes by the ftate of the running. 

Inflammation of the teftes very rare- 
ly terminates in fuppuration : but this 
fhould not prevent the moft timeous ap- 
plication of thofe remedies which we 
know to be the mofl: powerful difcutients. 
Blood-letting is perhaps the moft effec- 
tual remedy ; but it always proves mofl; 

fer- 



404 Of Acute or Ch. XXXVIII. 

ferviceable when the blood is taken di- 
redly from the part afFecled by means 
of leeches. After difcharging a fuffi- 
cient quantity, the fwelling fliould be 
kept conftantly moid with a folution of 
Saccharum Saturni ; the fcrotnm and 
teftes flionld be properly fnfpended ; the 
bowels (liould be kept moderately open ; 
a low diet fliould be prefcribed ; and the 
patient fliould be ftriftly confined to a 
horizontal podure. When there is the 
lead reafon to fufpecl that the conflitu- 
tion is tainted with lues venerea, nothing- 
will prove ferviceable if a mercurial 
courfe be neglecled. And when it ap- 
pears that the difeafe has been induced 
by the difcharge having been too fud- 
denly checked, we (liould endeavour to 
promote a retnrn of it, by bathing the 
penis in warm water ; by injcding warm 
oil into the urethra ; or by the ufe of 
bougies. 

By due attention to a courfe of this 
kind, almofl every cafe of inflamed te- 
flicle will terminate favourably ; that is, 

the 



Se6t. II. Inflammatory Tumors. 405 

the tumor will be difcuflecl. But when 
the contrary happens, either from the 
ufe of the remedies not being perfifled 
in, or from the inflammation being par- 
ticularly violent, and when fnppuration 
is found to take place, the matter mud 
be difcharged by an opening made in 
the moft depending part of the abfcefs ; 
which in every refpecl fliould be treated 
like colledlions of pus in other parts of 
the body. 



S 7- Of Venereal Buboes. 

Swellings in the lymphatic glands 
from the abforp^tion of the venereal vi- 
rus are termed Venereal Buboes. They 
may appear in any gland feated between, 
a venereal fore and the heart: but they 
are moft frequent in the groin, in confe- 
quence of the abforption of venereal 
matter from fores in the penis. For the 
moft part they are produced by matter 
abforbed from chancres, and in fome 

cafes 



4o6 - Of Acute or Ch. XXXVIII. 

cafes from the matter of a gonorrhoea : 
But inftances likewife occur of buboes 
arifing without any previous ulceration 
or difcharge from the penis, where the 
matter appears to be ablorbed without 
any perceptible erofion of the fltin. 

The mod material point to be deter- 
mined In the treatment of a bubo is, 
whether we fhould endeavour to difcufs 
the fwelling, or to bring it to fuppura- 
tion ? While it was imagined that bu- 
boes were produced by a depofition of 
venereal matter from the fyftem. It was 
not furprifing to find pradlitioners ad- 
vifing us in every Inftance to promote 
their fuppuration : for on this fuppoli- 
tion It was probable that nature meant 
to throw off the Infedlion. But now 
when we know that buboes arlfe from 
matter paffing into the fyftem, that the 
quantity of venereal matter Is increafed 
inflead of being dlmlniflied, by their be- 
ing brought to fuppurate ; and that the 
fores which enfue from them are often 
extremely difficult to cure ; fcarcely any 

will 



Se£t. II. Inflammatory Tumors. ^oj 

will doubt of the propriety of endea- 
vouring to remove them by difcuilion. 

With this view the patient fhould be 
put upon an antlphlogiftic regimen. I 'is 
bowels fliould be kept open by the 
ufe of purgatives ; leeches fhould be 
applied to the hardened gland ; and it 
lliould be kept conftantly wet with a 
ftrong folution of Saccharam, Saturni. 
Along with thefc, however, mercury 
fhould be given in quantities fufficient 
for eradicating the difeafe : And as we 
know from experience that mercury 
proves moO: efFedual when it is made to 
pafs through the difeafed glands, it fhould 
always be applied in the form of un<5lion 
to thofe parts in which the lymphatics 
of the afFeded glands are known to ori- 
ginate : a practice which will almoft 
uniformly be found to prove more effec- 
tual than the diredl application of the 
mercury to the glands themfclves. Thus 
in the difcuilion of a bubo in the groin, 
fri<5lion with mercurial ointment upon 
the thigh and leg will prove more luc- 

cefsful 



4o8 « Of Acute or Ch/XXXVIIL 

cefsful than rubbing it upon the gland 
itfelf. To many this has been long 
known ; and it would appear that the 
pradice could fcarcely fail of occurring 
to any who have paid attention to the 
difcoveries made by the moderns in the 
anatomy of the lymphatic fyflem*. 

When buboes are early noticed, the 
courfe we are now recommending will 
feldom fail in difcufling them, if the 
mercurial fridlions be properly applied 
and continued for a fufficient length of 
time. It often happens, however, that 
all our efforts fail, either from the dif- 
eafe being too far advanced before the 
mercury is applied, or from the tumor 
not being altogether venereal, but of a 
mixed nature ; a circumftance which is 
not unfrequent. Thus it, frequently 
happens that buboes are combined with 
fcrophula and fcurvy, and in fome cafes 

with 

* Farther information may be obtained on this point 
in a late elaborate publication on the venereal difeafe, by 
the very, ingenious Mr John Hunter of London. 



Bed.. II. Inflammatory Tumors.- 409 

with eryfipelas or with common phleg- 
mon. In fuch cafes we are not furpri- 
fed at the failure of mercury: and ac- 
cordingly we fometimes find, that in- 
ftead of forwarding the difcuffion of the 
fwelling, it tends evidently to bring it 
to fuppuration. Cafes of this kind prove 
often very perplexing both to the pa- 
tient and practitioner ; i^o that no point 
in pradlice requires more exa(5l atten- 
tion and difcrimination : For by pro- 
ceeding to throw in great quantities of 
mercury, as is ufually done while buboes 
continue obllinate, we often do harm, 
not merely to the local afFedlion, but to 
the fyftem at large ; at the fame time 
that in every inftance the fafety of the 
patient requires fuch a quantity to be 
exhibited as is fufficient for eradicating 
the venereal virus. In all fuch cafes, 
the bed pradlice, I believe, is to defift 
from the ufe of mercury as foon as it 
appears that no advantage is derived 
from it. In the mean time, by a change 
of diet and other circumftances, fuch an 
Vol. V. D d alee- 



41 o Of Acute or Ch. XXXYIIL 

alteration may be effeded in the confli- 
tution, that a fecond trial of mercury 
may prove fuccefsful : At leaft, in diffe- 
rent inftances this has fucceeded with 
me, where I had much reafon to think 
that perfirting longer with mercury at fird 
would have done much harm. 

When it is found that a bubo cannot be 
difcafTed, and that it will probably fuppu- 
rate, a frequent renewal of warm emol- 
lient poultices and fomentations are the 
remedies to be moll depended upon. 

The opening of buboes when fuppu- 
ration has taken place next demands our 
attention. Some diflbade us from open- 
ing buboes at all, alledging that they heal 
fooner when allowed to burft of them- 
felves : while a fmall pundlure with a 
lancet, a longitudinal cut through the 
"whole extent of the fwelling, or the ap- 
plication of cauflic, have all had their 
abettors. 

When a bubo is altogether venereal,, 
and not connecSled with any other dif- 
©rder, any of thefe methods will fucceed, 

pro>- 



Seft. II. Inflammatory Tumors. 411 

provided a fufficient quantity of mer- 
cury be exhibited : But when a bubo 
terminates In a fore difficult of cure, we 
are too apt to blame the particular me- 
thod in which it was opened ; for in 
whatever manner it is done, we know- 
that the cure will often prove tedious 
and perplexing. 

The objecfl of pra(5litioners fhould be 
nearly the fame here as in collections 
of matter in any other part. Such an 
opening fliould be made as affords a free 
vent to the matter ; but there is feldom 
any necedity for making it larger. In 
very large buboes, indeed, the tegu- 
ments are apt to be £0 loofe and flabby, 
and the texture of the fkin fo much de- 
flroyed, that the cure would be render- 
ed tedious were it allowed to remain. 
In fuch cafes it is advifable to difcharo-e 

to 

the matter with cauftic applied in fuch 
a manner as to dellroy any part of the 
teguments that are fuperabundant. This, 
however, is iHdom necefTary ; and for 
the moft part it will be found that an 
D d 2 opening 



412 Of Acute or Ch. XXXVlIf. 

opening made from the center of the tu- 
mor, where the matter commonly points, 
down to the moft depending part of it, 
will prove fufficient. Even a fmaller 
opening than this would often anfwer ; 
but it is better to make it of a fufficienn 
fize at once, than to be obliged to repeat 
a very painful operation perhaps once 
and again, as is often necejrary when 
buboes of a large fize are opened by 
fmall pun(n:ures. In fmall buboes, a 
mere puncture will fometimes prove fuf- 
ficient ; nay in thefe, the matter being 
allowed to burfl, often anfwers extreme- 
ly well : but when the colledion is large, 
this fhould never be depended on. 

When buboes come forward to full 
maturation without much injury being 
done to the fkin, I have in different in- 
ftances difcharged the matter by the in- 
crodudtion of a fmall cord ; and the 
practice has fucceeded. This requires, 
however, the teguments to be firmer 
than they commonly are when a bubo is 
ready to be opened. 

We 



Sed. II. Infammatory Tumors^ 41^ 

We all know that it is of much im- 
portance to prevent the air from finding 
accefs to fores ; and as we fometimes ob- 
ferve buboes ooze out the matter which 
they contain by a number of fmall open- 
ings over their furface, and as thefe 
commonly heal eafily, I conclude that 
they do fo from the openings being fo 
fmall as to exclude the air entirely. In 
different cafes, I have attempted to imi- 
tate nature, by making a number of very 
fffmall pundlures with the point of a lan- 
cet over the whole extent of the bubo ; 
and for the moft part with fuccefs. The 
matter comes flowly off; the fides of 
the abfcefs contradl gradually ; and whea 
it is completely emptied, we commonly 
find the whole parts that have been affec- 
ted fufficiently firm, without any fores or 
finufes remaining. 

While means are employed to promote 
the fuppuration of a bubo, the patient 
fhould flill continue the mercurial courfe, 
by which no time will be loft ; and the 
fore, which is the confequence of the 
D d 3 opening. 



414 Of Acute or Ch. XXXVIII. 

opening, will afterwards heal more quick- 
ly than it the mercury had been inter-^ 
rupted. The fore, however, often proves 
tedious, even where we are convinced 
that a fufficient quantity of mercury has 
been given, and where there is every 
reafon to fuppofe that the fiphylitic vi- 
rus is eradicated. The edges become 
hard and livid ; the matter, thin, fliarp, 
and fetid ; and inftead of healing, the 
ulceration gradually becomes more ex- 
tenfive ; or if it heals in fome parts, it 
breaks out in others, giving a honey- 
comb appearance to all the under pare 
of the abdomen and upper part of the 
thigh. 

The fituation of patients with fuch 
fores is truly deplorable. The pain 
with which they are attended is often 
intenfe ; the abforption of acrid matter 
induces hedlic fever ; they become hot 
and reftlefs through the night ; and al- 
moft a total want of appetite renders them 
foon very emaciated, 

Ast have happened to be concerne4 

m 



Se£l:. IT. Inflammatory Tumors. 415 

in a confiderable number of fr.ch cafes, 
I can fpeak with fome confidence of the 
method of treatment. In the firfl place, 
we mnfl conclude that the patient has 
taken a fufficient quantity of mercury, 
and that no finufes are left in which 
matter in any quantity will be allowed 
to lodge. CIcuta in fuch circumflances 
has fometimes proved ufeful ; and I 
have had different inflances of the ex- 
ternal application of it healing the lores, 
when no advantage was derived from 
any kind of ointment. In fuch cafes it 
was applied in the form of poultices, by* 
mixing the juice of the frefh herb with 
the common emollient cataplafm. I 
have fometimes obferved too, that in the 
internal exhibition of cicuta, ttie recent 
expreffed juice has proved more effediual 
than any other form of it, I have gi- 
ven the hyofcyamus and belladona very 
complete trials in various inftances ; but 
no material advantage has ever enfued. 
from them. 1 have not feen any evi- 
dent effefts either from farfaparilla or 
D d 4 guaiac % 



4^6 Of Acute or Ch. XXXVIII. 

guaiac ; but mezereon has In different cafes 
proved ufeful. In two inftances of very 
extenfive fores, of this kind, where the 
whole groin and contiguous parts were 
ulcerated, and where none of the reme- 
dies mentioned above, nor any of the 
ufual dreffings, had any effedl, the pa- 
tients were evidently cured by mezereon 
alone. A drachm and a half of the 
rhind of the root, with two drachms of 
liquorice-root, boiled in three Englill^ 
pints of water into a quart, makes a de- 
codlion of a fufficient flrength. This 
quantity may be ufed daily. 

But the moft effectual courfe I have 
hitherto tried, is the application of cau- 
ftic round all the edges and hardened 
parts of the fores, at the fame time that 
opium in confiderable quantities is given 
inwardly. For a conflderable time 1 
trufted entirely to dreffings of the emol- 
• lient kind, being afraid of irritating 
parts already extremely fenfible. In . 
ihvne cafes a faturnine ointment has pro- 
ved fuccefsful ; and in others the com- 
mon 



Se£t. II. Inflammatory Tumors. 417 

mon calamine cerate has anfwered ; but 
for the moft part, on thofe days in which 
cauftic is not applied, I have found more 
advantage from the ufe of red precipi- 
tate than from any other remedy. In 
fome cafes it is neceffary to fprinkle it 
over the furface of the fore in the form 
of a dry powder ; but in others it proves 
fufficient to add it to any of the com- 
mon ointments. Inftead of creating pain, 
it commonly removes it ; and it leldom 
fails to alter the difcharge from a thin 
Iharp fanies to a thick well digefted pus. 

At firft the application of lunar cau- 
ftic fometimes gives pain : but this foon 
fubfides, and efpecially when opium is 
ufed at the fame time. Indeed opium 
of itfelf proves often ufeful in fores of 
this kind. It has been highly extolled 
of late for the cure of every ftage of the 
venereal difeafe. I have had no proof 
of its ever curing any fymptom truly 
venereal ; but I have had feveral in- 
ijtances of fores remaining after the ve- 
nereal 



41 8 Of Acute or Ch. XXXVIIL 

nereal dlfeafe, even when large quanti- 
ties of mercury had been given in vain, 
being completely removed by it. It of- 
ten appears that fores of this kind, as 
well as others proceeding from different 
caufes, are kept up by that pain and ir- 
ritation with which they are uniformly 
accompanied when the matter is thin 
and acrid. To me the utility of opium 
feems to depend entirely on its narcotic 
or anodyne powers. By removing this 
ftate of irritability, it deftroys the dif- 
pofition in the veffels of the fore to form 
that kind of matter which by its acri- 
mony ferves to perpetuate itfelf: and 
this being accomplifhed, if no other in- 
terruption takes place, nature alone will 
feldom fail to complete the cure. If this 
idea be well founded, there can be no 
neceflity for giving opium in fuch large 
quantities as of late have been advifed. 
On the fuppofition of opium being pof- 
fefled o-f fome fpecific powers in the cure 
of the venereal difeafe, it has been given 
in as large dofes as the patient could 

poilibly 



Sed. II. Inflammatory Tumors. 419 

poffibly bear ; and by beginning with 
fmall dofes, and increafing them gra- 
dually, there have been fome inftances 
of its being taken to the extent of half 
a drachm or more two or three times a- 
day. I have not heard, however, that 
any advantage has been derived from 
giving it in thefe large quantities, that 
did not accrue from a more moderate 
ufe of it : And in the courfe of my own 
experience, I have found it equally ef- 
fedtual when it merely lefTened or remo- 
ved pain, as when given in the largeft 
dofes ; while the inconveniences which 
ufually arife from thefe have in this man- 
ner been avoided. 



§ 8. Cy Lumbar Abfcejfes. 

Every collecflion of matter feated on 
any part of the loins, may be denomina- 
ted a Lumbar Abfcefs. But it is that 
variety of the difeafe we are now to con- 
iider, which originates about the fupe- 

rior 



420 Of Acute or Ch. XXXVIII. 

rior part of the os facrum ; and in which 
we find, by difTedlion, that the matter 
contained in a cyft, is lodged on the an- 
terior furface of the internal iliac and 
pfoas mufcles, 

Thefe abfcefles are always preceded by 
pain and tenfion over the loins ; which 
often flioots up along the courfe of the 
fpine, and down towards the thighs ; and 
often with difficulty of (landing eredl. — 
In fome cafes, thefe fymptoms are fu- 
fpecSled to be nephritic ; but for the mofl 
part the difeafe afTumes the appearance 
of lumbago. When fuppuration enfues, 
fliivering fits are apt to occur : but the 
pain, which at firft was acute, becoming 
dull and lefs perceptible, the patient is 
led to conclude that he is getting better, 
till the matter, after falling down in a 
gradual manner behind the peritonseum, 
is obferved to point outwardly, either at 
the anus by the fide of the redlum, or on 
the upper and fore part of the thigh, 
where the large blood-vefTels pafs oat, 

be- 



Sefl:. II. Inflammatory Tumors. 421 

beneath Pauparc's ligament, fiom the ab- 
domen. 

When the matter rakes the courfe of 
the gut, and appears near to the anus, it 
either foon burfts, or is hiid open on the 
fuppofition of its being an abfcefs origi- 
nating in the contiguous parts. But 
when it pafTes down with the foemoral 
artery, which we find to be mod fre- 
quently the cafe, as it lies deep, and is co- 
vered with the ftrong tendinous fafcia of 
the thigh, inftead of pointing at any par- 
ticular part, it falls gradually lower, till 
in fome cafes it reaches near to the joint 
of the knee. 

The tumor is feldom attended with 
more pain than might be expelled to 
occur from the diftention of the fafcia 
and contiguous parts by the matter col- 
le(5led beneath. There is no difcolour- 
ing of the fkin ; the teguments, for the 
moft part, retaining their natural ap- 
pearance to the laft. A fluduation of a 
fluid is evidently difcovered through the 
whole extent of the tumor, particularly 

when 



422 Of Acute or Ch. XXXVIII. 

when the patient is erecl ; for at this 
time the fvvelling is always much more 
tenfe than when the body is lying in a 
horizontal pofturc, when a confiderablc 
part of the matter runs along the fac to- 
wards its origin in the loins. 

We have already obferved, that this 
variety of abfcefs, when the matter falls 
down towards the anus, may be mifla- 
ken for a common phlegmon originating 
in the neighbourhood of the redum. 
But no farther inconvenience can occur 
from this miftake, than that the fore, 
which enfues from laying it open, or from 
the matter burfting out, will not fo rea- 
dily heal as when the difeafe is merely 
local : And it is probable that this is one 
caufe of abfcelles in thefe parts being in 
fome inftances fo difficult to cure. But 
in the more ordinary form of the dif- 
eafe, where the matter falls down be- 
neath Paupart's ligament, the tumor ex- 
hibits appearances fo fimilar to thofe of 
a crural hernia, that the one has often 
been miftaken for the other. Of this I 

have 



Seft. II. Inflammatory Tumors. 423 

have feen different inftances, even where 
pradlitioners ot experience were decei- 
ved. This proceeds, however, from in- 
attention ; tor the two difeafes may be 
clearly diltinguifhed from each other. 

The hiftory of the rife and progrefs of 
the fwelling fhould be firft attended to. 
A crural hernia ulually appears fudden- 
ly, without any previous fymptom, after 
fome unufual exertion ; and ior the moft 
part it is attended with obflrudlion to the 
paflage of the faeces, with vomiting, and 
other fymptoms of hernia : And from 
the firfl, the tumor is attended with pain 
on being handled. But in the lumbar 
abfcefs, before the matter appears at the 
top of the thigh, the patient is previoufly 
diftrelfed with the fymptoms of inflam- 
mation over all the under part of his back 
and loins. No obftrudlion of the bowels 
takes place, nor any fymptom of hernia ; 
and the patient admits of the tumor be- 
ing freely handled. In the crural her- 
nia, the fwelling feldom arrives at any 
confiderable bulk ; and when it does be- 
come 



424 Of Acute or ' Ch. XXXVIII. 

coQie large, it Is by flow degrees : no 
fiudluation is perceived in it ; but, on the 
contrary, it feels either foft like dough, 
or knotty and unequal, according as the 
omentum or faeces contained in it have 
been long lodged in it or not. But in 
the lumbar abfcefs, the tumor commonly 
falls quickly down the thigh for the 
fpace of feveral inches ; a fla(5luation is 
always perceived ; and no inequalities are 
obferved in it. In the hernia, even when 
it is not (Irangulated, fome degree of 
preffure is ufually neceflary, even when 
the patient is in an horizontal pofture, to 
make the contents of the tumor recede. 
But in the lumbar abfcefs, the tumor be- 
comes flaccid immediately on the patient 
lying down, whether any prefliire be ap- 
plied to it or not : And it often happens, 
when the matter has fallen any confi- 
derable way down the thigh, that the 
upper part of the cyft at the top of the 
thigh is found perfedly clear ; that is, 
a certain fpace can be difcovered be- 
tween the upper part of the matter 

and 



Sedi. II. Inflammatory Tumors. 425 

and the inferior boarder of the abdo- 
minal mufcles, which can never be done 
in any kind of hernia ; and which there- 
fore, in this ftate of the difeafe, is always 
a certain means of diftindion. It is 
fcarcely neceflary to obferve, that in. 
this examination the patient fhould be 
eredl. 

By due attention to thefe circumffcances 
we may always diflinguifli one of thefe 
tumors from the other. Both indeed may- 
occur at the fame time in the fame thigh, 
by which a mixture of appearances will 
be produced. This, however, mufl. be 
extremely rare ; and when it dpes take 
place, as the matter of the abfcefs and 
the parts protruded from the abdomen 
will always be contained in feveral facs, 
the combination will be eafily difcover- 
ed. % 

In the treatment of thefe a£fe<5lions, 
the period of the diforder firll requires 
our attention. In the inflammatory ftate 
of the difeafe, the ftridleft antiphlogiftic 
^ourfe fhould be adopted, in order if 

Vol. V. E e poffible 



425 Of Acme or Ch. XXXVIII. 

poffible to prevent the formation of mat- 
ter. For the mod part, we difcover, that 
it has been induced by the fmall of the 
back or loins having received fome con- 
fiderable injury, either by a twift or a 
fevere bruife : and if accidents of this 
nature were immediately treated with 
that attention which their importance 
merits, thofe difagreeable confequences 
which are apt to enfue from them might 
frequently be prevented. Whenever it is 
found that a patient, who has fufFered in 
this manner, complains of fevere pain in 
the injured part, blood-letting (hould be 
immediately advifed j and as local blood- 
letting proves always in fuch cafes moft 
eflfedual, it fliould be done by cupping 
and fcarifying the pained part. The af- 
feded parts being deeply covered, the 
lancets of the fcarificator fliould be made 
to go to a confiderable depth ; for which 
purpofe the fpring of the inftrument 
fhould be ftronger than ufual, by which 
means any quantity of blood we may 
judge proper may be taken with eafej 

and 



Sed. II. Inflammatory Tumors, 427 

and I am convinced, that by carrying 
this prafliee a fufficient length, we might 
very commonly, in the early (lages of 
the difeafe, remove it entirely. It is 
difficult to Tay when injuries of thefe 
parts would terminate in fuppuration or 
Gtherwife; but I have met with differenc 
inftances, where, from the feverity of 
the pain and other fymptoms, there was 
much caufe to fufpecft that matter would 
have formed, if it had not been prevented 
by a timeous and plentiful difcharge of 
blood from tlie injured parts ; a remedy 
which commonly gives immediate relief 
to the pain, however violent it may be. 
But at the fame time that we depend 
chiefly on local blood-letting, other re- 
medies which experience (hows to prove 
ufcful in inflammation fhould not be ne- 
glected : Of thefe, blifters, opiates, and 
gentle purgatives, are to be moil relied 
on. 

Thefe, however, as well as every other 

remedy, will in fome inftances fail ; and 

in others, practitioners are not called 

E e a til 



428 Of Acute or Ch'. XXXVIIT. 

till fuppuracion has taken place, and till 
the matter has a^lually begun to point, 
either in the neighbourhood of the anus 
or on the tore-part of the thigh. In this 
fituation, what are we to do ? Are we to 
allow the matter to remain, or to dif- 
charge it by making an opening into it ? 
In my opinion there is no room for he- 
fitation : The matter fhould be evacua- 
ted as foon as a fluduation is diftindlly 
perceived in the tumor. 

I know, however, that prat^litionerg 
are of different opinions upon this point : 
fbr it is alledged, that as thefe abfcefles are 
fo deeply feated, it would be in vain to 
attempt the cure of them ; and therefore 
that no advantage can be derived from 
their being laid open ; while much harm, 
they obferve, may accrue from the air be- 
ing freely admitted to them. But it does 
not appear that this reafoning is founded 
on obfervation. I have always held it as 
a leading principle in furgery, that the 
matter of every abfcefs feated near to any 
of the large cavities of the body fhould 
be difcharged as foon as its exiftence is 

clearly 



Se6t. II. Inflammatory Tumors. 429 

clearly afcertained : So that in the treat- 
ment of the lumbar abfcefs, I have uni- 
formly given vent to the matter, with- 
out any bad confequences enfuing ; while 
much mifchief may occur from this being 
omitted. We find by difTecftion after death, 
that thefe abfcefles, when of long dura- 
tion, afFetl not only thefofter parts cover- 
ing the vertebra* of the loins, but the fub- 
flance of the vertebrae themfelves ; which 
in fome cafes have been found carious, 
and even partially dilTolved in the matter 
of the abfcefs. Now thefe accidents are 
furely more likely to happen when the 
matter is allowed to continue in the ab- 
fcefs, that when it is difcharged : at the 
fame time, by emptying the fac, the mat- 
ter is prevented from burfting into the 
cavity of the abdomen : which in dif- 
ferent inflanc!es has happened, to the 
great inconvenience and hazard of the 
patient. The matter, however, ought 
certaiiily to b^ difcharged in fuch a way 
as to prevent the air as effecftually as 
pofiible from getting accefs to the cavity 
E e 3 of 



430 Of Acute or Ch. XXXVIlt. 

of the abfcefs. With this view a trocat 
may be iifed with advantage. By preiling 
the matter down to the mofi: depending 
part of the abfcefs, the ikin is made To 
tenfe, that a trocar is readily introduced. 
I tried this in 6ne cafe with very com- 
plete fuccefs; and the patient wore a 
fmall canula in the opening for feveral 
months, by which the matter was freely 
difcharged. But when the cafe is not 
perfectly obvious, and when the lead 
doubt remains in the mind of the furgeon 
with refped to the contents of the tumor, 
inftead of puOiing a trocar into it, the o- 
pening fliould be made in a flow gradual 
manner with a fcalpel, in the fame man- 
ner as is pradifed in cafes of hernia ; fo' 
that in the event of any of the contents 
of the abdomen being down^ no injury 
may be done to them* 

After the matter has continued to flow 
for fome time, and if at the end of two 
or three v^^eeks the quantity does not be- 
come confiderably lefs, it may prove ufe- 
ful to throw up with afyringe a weakfolu- 

tion 



Sed. 11. Inflajmnaiory Tumors. 431 

lution of faccharum faturni, lime-water, 
or fbme other gentle aftringent ; by which 
the difcharge will be gradually ditninifh- 
ed, till at laft it ceafes entirely. But al- 
though this fhould never happen, and 
although the patient, during life, fliould 
fubmit to the inconveniency of a conftant 
flilllcidium of matter from the fore ; yet 
even this would be preferable to the rifle, 
allowing every abfcefs of this kind to re- 
main unopened. 

As I have happened to meet with ma- 
ny inftances of this difeafe ; as pradicio- 
ners are divided in opinion refpedling it ; 
and as no diftindl account of it is given 
by authors ; I have confldered it more 
particularly than I otherw^ife might have 
done. 



§ 9. 0/" the Paronychia or Whitlow. 

The paronychia is a painful inflam- 
matory fwelling, occupying the extremi- 
ties of the fingers under the nails. 

E e 4 Se- 



4T,i Of Acute or Ch. XXXVIII. 

Several varieties of this difeafe are de- 
fcribed by authors ; but there are three 
only which require to be diftinguifhed, 
and even tbefe are all of the fame nature, 
the one being only more deeply feated 
than the others. 

In the firft, the patient complains of an 
uneafy burning fenfation for fevcral days 
over the point of the finger ; the pare 
becomes tender and painful to the touch ; 
a flight degree of fwelling takes place, 
but vvith little or no difcoloration j and 
if the inflammation be not removed by 
refolution, an efFufion is at laft produced 
betviT^een the fliia and the parts beneath. 
On difcharging this by an incifion, it 
is found to be a thin, clear, acrid fernm j 
and the removal of it, in general, gives 
immediate and complete relief. 

In the fecond variety of the difeafe 
the fame fet of fymptoms are produced j 
only the pain is more fevere, and it is 
attended with fome uneafipefs over the 
whole finger and hand. The efFufion 
which takes place is not fo perceptible 

as 



Sed. II. Inflammatory Tumors. 433 

as in the other ; and on laying it open, 
it is found to lie beneath the mufcles of 
the finger, between thefe parts and the 
periofteum. 

And in the third, the pain is ftill more 
intenfe in the point of the finger, at the 
fame time that the whole hand and arm 
becomes ftiff^, fwelled, and painful. The 
lymphatics leading from the finger, and 
even the glands in the arm-pit, fwell, 
and inflame j and on making an inci- 
fion into the efFufion, it is found to lie 
between the periofteum and bone, the 
whole phalanx being in general cari- 
ous. 

Swellings of this kind may be produ- 
ced by various caufes. They frequently 
occur from external violence, particular- 
ly from pundlures and contufion : But 
they happen more frequently from cau- 
fes, the nature of which we are not ac- 
quainted with. 

There are two fets of remedies em- 
ployed in paronychia : The one confifts 
of fomentations, poultices, and other 

emol- 



434 0/ ^cute or Ch. XXXVlIL 

emollients ; the other of ardent fpirits, 
vinegar, and other aftringents. 

As we find from experience that no 
acl vantage is ever produced by the effu- 
fion which occurs in this difeafe ; but on 
the contrary, that it is always produdive 
of much additional pain, all thofe appli- 
cations Ihould be avoided which have 
any tendency to promote it. Some 
practitioners have been induced to make 
ufe of warm poultices, with a view to 
promote the fuppuration of the fwelling, 
after they have had reafon to believe 
that effufion has taken place. But I 
have never obferved any advantage to 
accrue from them ; and as the ferum 
which we meet with in thefe colledlions 
is produced entirely from membranous 
parts, I do not fuppofe that it can be 
converted into pus ; at leaft none of 
the remedies I have known employed 
have ever been able to effe<£l it. I 
endeavour therefore in every inftance 
to prevent this effufion from taking 
place ; by local blood-letting, and by the 

ufe 



Se£t. II. Inflammatory T'umdrs. 435 

ufe of aftringents. Indeed the fame re- 
medies ^prove mod effediual here which 
are ufeful in the removal of inflamma- 
tion in other parts. I have had different 
inflances even of very violent degrees of 
pain being almoft immediately removed 
by the application of feveral leeches over 
the difeafed phalanx of the finger. But 
in the more violent degrees of it, where 
the arm fwells, and by which fever 
is fometimes produced, general blood- 
letting is likewife necefTary, at the fame 
time that large dofes of opiates are in- 
dicated. 

After as much blood is difcharged by 
the leeches as is judged proper, the im- 
merfiou of the pained parts in ftrong 
brandy, or even in fpirit of wine or al- 
cohol, is one of the befl remedies : And 
when the bites are fomewhat healed, or 
when leeches have not been employed, 
fpirit of turpentine or ftrong vinegar may 
be ufcd in the fame manner. 

It is proper to remark, however, that 
it is in the firft ftages only of this affec- 
tion 



436 Of Acute or Ch. XXXVIII. 

tion that remedies of this kind can prove 
ufeful : for when effufion has adlually 
taken place, the flate of the dlfeafe is 
produced which they were meant to pre- 
vent ; and it does not appear that they 
have any effecl in removing it. As food 
as we are convinced that effufion has oc- 
curred, an opening Hiould be made with- 
out delay : For we have already obferved, 
that it is in vain to attempt to convert 
the effufed fluid into pus ; and being in 
itfelf acrid, it is apt to injure the conti- 
guous parts, while at the fame time the 
patient is kept in an extreme degree of 
pain as long as it remains confined. 
When the colleclion is fuperficial, and 
merely covered with fkin, this is a very 
fimple operation, A punclure with a 
lancet commonly proves fufficient : But 
when the matter is more deeply feated, 
it requires fome attention to avoid the 
flexor and extenfor tendons of the finger. 
When the matter lies above the peri- 
oftieum, all that we have to do is to 
make the opening fufliciently large for 

dif- 



Sed. II. Inflammatory Tumors. 437 

difcharging it, and to drefs the fore as if 
It was produced by any other caufe. 
But, when the matter lies between the 
periofteum and the bone, in every cafe 
that I have met with, the bone has not 
only been laid bare, but it has been 
found to be carious. The common 
practice is to endeavour to keep the in- 
cifion open till an exfoliation of the dif- 
eafed parts of the bone takes place ; but 
I have never obferved any advantage ac- 
crue from tliis. The procefs is not only 
extremely painful, but tedious. The 
matter is apt to lodge beneath the nail ; 
painful fungous excrefcences fproiit out 
over the fore, which it is difficult even 
with the ftrongefl: cauftic to keep under ; 
and at lafl: it has very commonly hap- 
pened, after the patient has fuffcrcd fe- 
veral months of diflrefs, that inftead of 
a partial exfoliation, the whole difcafcd 
phalanx has come away. I am tlierc- 
fore convinced, that much time and 
trouble would be faved both to the pa- 
tient and furgeon, if the difeafed bone 

were 



438 Of Acute or Ch. XXXVIIL 

were immediately removed on making 
the opening to difcharge the matter. By 
making a free incifion along the whole 
length of the difeafed phalanx, the bone 
is ealily removed with common forceps. 
The pain attending it is indeed fevere, 
but it is only momentary : and the mea- 
fure, which does not deprive the patient 
of the ufe of the joint fo much as might 
be imagined, is feldom oppofed when the 
furgeon advifes it. I have had feveral 
inftances of people who h^d in this man- 
ner loft the laft phalanx of bone in one 
of their fingers, having fuch a degree of 
firmnefs in the parts which remained, as 
to experience very little inconvenience 
from the want of it. 

When the difeafed bone is removed, 
the remaining fore commonly heals with 
eafe. It requires fome attention, how- 
ever, to preferve the lips of it from ad- 
hering till it fills up fron the bottom. 
This is done in the eafieft manner by in- 
fmuating a fmall pled git between them 

of 



Sed. II. Inflammatory Tumors, 439 

of foft lint, fpread with any mild emol- 
lient ointment. 

In every variety of the difeafe, except- 
ing in a few cafes of the mildeft kind of 
it, we find that the nail is apt to fall off: 
But this proves only a temporary incon- 
venience ; for when the parts are proper- 
ly proteded, nature never fails to fupply 
the deficiency. 

In the commencement of paronychia, 
it is the laft phalanx of the finger only 
that is affeded : And to whatever extent 
the pain and fwelling of the fofcer parts 
may fpread, we never find that the bone 
of the contiguous phalanx fuffers, unlefs 
from improper management in allowing 
the difeafed bone to remain, or the acrid 
matter to lodge too long. In fuch cafes, 
the furrounding teguments are apt to 
fwell and inflame, and fmall ulcerations 
to occur over the whole extent of the 
carious bone. In this fituation we are 
often under the neceffity of advifing the 
finger to be amputated, in order to pre- 
vent 



440 Of Acute or Ch. XXXVIII. 

vent the difeafe from fpreading to the 
hand. 



§ lo. Of Chilblains. 

These are painful inflammatory fwel- 
lings,, to which the fingers, toes, heels, 
and other extreme parts of the body, are 
liable, on being much expofed to fevere 
degrees of cold. The tumor is for the 
moft part of a deep purple, or fomewhat 
of a leaden colour : the pain with which 
it is attended is not conftant, but fhoot- 
ing and pungent ; and in general, it is 
accompanied with an infupportable de- 
gree of itching. In fome cafes the fkin 
remains entire, even although the tume- 
fadlion be confiderable ; but in others it 
burfts or cracks, and difcharges a thin 
fomewhat fetid matter. And- where the 
degree of cold has either been very great, 
or the application of it long continued, 
all the parts that have been afFe6led are 
apt to mortify and to flough off, when a 

very 



Se6t. II. Inflammatory Tumors, 441 

very foul ill-conditioned ulcer is always 
■^ left. 

We have obferved above, that it is the 
extreme parts of the body chiefly that 
are liable to be attacked with chilblains: 
and we likewife find that delicate chil- 
dren and old people are more apt to fuf-* 
fer by them than thofe who are robult. 
It is alfo remarked, that they are parti- 
cularly fevere In people of a fcrophulous 
habit. 

The beft preventative of chilblains is 
to avoid expofure to cold and dampnefs : 
And when once a perfon has fufFered 
from fwellings of this kind, if the inju- 
red parts be not protefted by fufficient 
coverings, he will be liable to a return of 
them every winter. Much diftrefs, 
therefore, and inconvenience, may be 
prevented by due attention to this cir- 
cumftance. 

The utmofl: care, however, will not al- 
ways prevent chilblains. In this cafe, 
it is often in our power to mitigate the 
complaint, by bringing the affeded parts 
Vol. V. Ff gra- 



442 Of Acute or Ch. XXXVIIL, 

gradually to their natural heat, inftead 
of warming them more quickly. The 
patient fhould not be allowed to approach 
a fire: inftead of which, he ihould be 
put into a cold apartment ; and the frofl- 
bit parts fhould firft be well cubbed 
with fnow, and afterwards immerfed in 
the coldeft water that can be procu- 
red : for nothing {q certainly proves 
hurtful to parts in this ftate as heat be- 
ing fuddenly applied to them. Even 
foow and cold water afford a warm 
fenfation to parts attacked with chil- 
blains ; but it is found by experience 
that no detriment enfues from this. Af- 
ter the parts have been treated in this 
manner, the patient may in a gradual 
way be brought into a greater degree of 
beat ; but he fhould for a confiderable 
time keep at a diftance from fire. Rub- 
bing the parts with fait will in this fitua- 
tion prove ufeful ; and immerfion in 
warm wine is llkewife employed with 
advantage. 

A patient much benumbed with cold 
fliould^ not even have cordials given to- 

biuL 



Sed. II. Inflammatory Tumors. ^% 

him fuddenly. A glafs of cold wine 
may at firft be allowed. Afterwards 
warm wine may be given, either by it- 
felf or mixed with fome of the warmer 
fpices : and when ftronger cordials are 
required, ardent fpirits may be employ- 
ed. 

Remedies of this kind, however, arc 
only necelTary in the more fevere de- 
grees of thefe affedlions. In common 
cafes of chilblains that occur in this 
country, as foon as the part is perceived 
to be affected, it ftiould be well rubbed 
cither with fpirit of turpentine, or with 
camphorated fpirit of wine ; and pieces 
of foft linen moiftened in one or other 
of thefe ftiould be kept conftantly ap- 
plied to it. In this manner we have it 
often in our power to remove fwellings 
which other wife would be produdlive of 
{nuch diftrefs : But we mu(l again ob- 
ferve, that the bed advice that can be 
given to fuch patients as are liable to 
them, is to protect the parts that are 
moft expofed to fuffer from cold as much 
Ffa ?i3 



444 Of Acute or Ch. XXXVIII. 

as pofTible during the winter j and when 
they accidentally get wet with fnow, 
which proves more particularly hurtful 
than any other kind of moifture, they 
fhould be as quickly cleared of it as pof- 
fible. 

As there are fome patients who fufFer 
fevcrely with chilblains every winter, 
either in their fingers, arms, toes, heels^ 
or lips, our being able to prevent them 
without that inconvenience which al- 
ways occurs from confinement and much 
caution, would often be an objed of im- 
portance ; and it is a point upon which 
praditioners are frequently confulted. 
I have had different inftances where fea- 
bathing during the fummer feafon has 
appeared to prove ufefpl : and in one 
patient who had fuffered feverely from 
the effeds of cold for feveral winters, I 
advifed a chamber-bath to be ufed even 
during the winter ; by which the parts 
which ufed to fiiffer were fo much 
ftrefigthened, that feveral years have elap- 
fed without any return of the difeafe. 

When 



Sedt. II. Inflammaiory Tumors. 445 

When chilblains ulcerate, by the tegu- 
ments being altogether thrown off, or 
merely cracking and oozing out matter, 
warm poultices and emollient ointments 
are commonly employed. For the pur- 
pofe of cleanfing the fores, and indu- 
cing a dlfcharge of right matter, poul- 
tices may with propriety be advifed 
for a few days ; but they (hould never 
be long continued : Nor fliould emol- 
lient ointments be much perfifted in ; 
for they very univerfally induce fungous 
excrefcences over the fores, which after- 
wards it is fometimes difficult to remove. 
The daily application of cauflic to the 
edges of the fore, and dreffing the fore 
itfelf with common digeftive ointment, 
mixed with a large proportion of red 
precipitate, are the beft preventatives of 
this. The common firaple diachylon 
plafter, fpread upon thin leather, makes 
an ufeful application for fores of this 
kind. 

Ff3 §11. 



446 Of Acute or Ch. XXXVIIL 



§ 1 i. Of Sprains and Contuftonsi 

Contusions of the fofter parts of tlie 
body, and fpiains of the tendons and lU 
gaments of joints, are ufually produc- 
tive of immediate painful inflammatory 
fwellings. 

The {lighter affeclions of this kind 
feldom meet with much attention ; but 
when the injury is fevere, it often re- 
(^uires the utmolt fkill of the pradition- 
er, as well as the greateft qaution on the 
pare of the patient, to remove thofe ef- 
fe(?ls wliich enfue from it, and which 
otherwife might continue during life. 

An increafed adlion in the arteries of 
^ny part, by which red globules are fofr 
ced into vefTels Vvhich naturally do not 
admit them, will account for all the 
phenomena which ufually attend infiam- 
tnation : But in the feverer degrees of 
Ipfains and contufions, along with an 
incr.ealed artion of the arteries in the 



Sed. II. Infianvmatory Tumors. 44.7 

part, which muft neceflarily refult from 
the pain with which they are accompa- 
nied, it is evident that inftantaneous ef- 
fufion likewife takes place, from the rup- 
ture of many of the fmaller vefTels of 
the part. In no other way can we ac- 
count for thofe very confiderable tumors 
which often rife immediately after in- 
juries of this nature. For the mod part 
the efiPufion muft be of the ferous kind, 
as the fkin ufually retains its natural co- 
lour for fome time after the accident: 
But the tumefied parts are fometimes of 
a deep red, and on other occafions of a 
leaden colour, from the firft ; owing to 
a rupture of fome of the vefTels contain- 
ing red blood. 

In the treatment of fprains and contu- 
fions, there are two circumftances which 
chiefly require attention. In the firft 
place we fhould endeavour to prevent the 
fwelllng, as far as it can poflibly be done, 
and afterwards thofe remedies fhould ha 
employed which we know to prove moft 
F f 4 ' power- 



448 Of Acute or Ch. XXXVllI. 

powerful in preventing or removing in-»- 
flaramation. 

It is alledged, indeed, by feme pradi- 
tioners, that the fwelling which occurs 
from this injury never does harm, and 
therefore requires no particular atten- 
tion. In contufions of the cellular fub- 
ftance, or even of the mufcles, I allow 
that this is often the cafe ; for to what- 
ever extent the tumefadion may proceed, 
the efFufed fluid is in thefe parts very 
commonly abforbed. But even here the 
fwelling in fome cafes proves extremely 
obftinate : and in fprains of the tendons 
and ligaments, a very troublefome, pain- 
ful thicknefs of the parts that have been 
injured, is apt to continue for a great 
length of time ; in fome cafes, even for 
life : And I have commonly obferved, 
that this has in general been nearly in 
proportion to the fize of the tumor which 
occurred at firfl ; for it would appear 
that effuiions thrown out by ligamentous 
parts are not fo readily abforbed as thofe 
which occur in other parts of the body. 

Hence 



Seft. 11. Inflammatory Tumors. 449 

Hence in every accident of this kind, it 
is an objedl of importance to prevent the 
fwelling from arriving at any confider- 
able magnitude. 

With this view, aftringent applications 
are moft to be depended on ; fuch as the 
lees of red wine, ardent fpirits of every 
kind, and vinegar. By immerfing a 
fprained or contufed part in any of thefe 
immediately on receiving the injury, if 
the efFulion be not altogether prevented, 
it will at lead be rendered much lefs 
than otherwife it probably would be. 
And it often happens that the immediate 
application of cold proves equally ufeful. 
plunging a fprained limb into the coldeft 
water that can be procured, or even into 
water rendered artificially colder than 
natural, is a pradlice that often proves 
ufeful ; and it fhoulci be always advifed 
in the firft place, till one or other of the 
articles mentioned above can be procu- 
red ; for as the efFufion takes place, as 
we have already obferved, very quickly, 

no 



4SO Of Jcute or Ch. XXXVIIL 

no time (hould be loft in the application 
of the remedies. 

It fortunately happens, that thofe ap- 
plications which prove moft efFed:ual in 
preventing the eftnlion that enfnes from 
fprains, prove likewife ufeful in prevent- 
ing inflammation. But as this fymptom 
is in fevere fprains apt to proceed to a 
great height, other remedies are requi- 
red in the treatment of it; and none 
that 1 have ever employed prove fo ef- 
fecftual as local blood-letting. By the 
time that the cold water and other d'lC- 
cutients we have mentioned may he fup- 
po fed to have produced any effeft, which 
will be in the fpace of an hour, a num- 
ber of leeches fhould be applied over all 
the tumefied part; or, in contufions of 
flefhy mulcular parts, cupping and fcari- 
fying will be found to anfwer equally 
well. But in whatever way it be done, 
a quantity of blood fhould be drawn off 
fomewhat proportioned to the ftrength 
of the patient and violence of the in-^ 
jury. 

For 



Sed. II. Inflammatory Tumors. ^^i 

For a confiderable time I have been in 
the conftant pradice of employing local 
blood-letting in fprains and contufions of 
every kind ; and in all of them, whe- 
ther the injury has been flight or fevere, 
it has proved an ufeful pleafant remedy. 
In the flighter kind of fprains, one plen- 
tiful evacuation of blood by means of 
leeches, will in general prove fufficient. 
But when the parts are much injured, we 
are under the neceflity of applying them 
repeatedly. They fhould be ordered in- 
deed from time to time as long as any 
confiderable pain remains in the affedled 
parts. Even when the inflammation and 
fwelling of the teguments are entirely 
gone, a fulnefs or thickening is often dif- 
covered in the tendons and other deep 
feated parts ; and we conclude, that they 
continue inflamed, as long as they are 
much pained either upon prefllireor upon 
motion. In this fituation nothing ever 
proves fo effe(n:ual as the application of 
leeches: The remedy indeed feems to 
prove equally ufeful, whether the inflam- 

matibn 



452 Of Acute or Ch. XXXVIII. 

mation be feated entirely in the fkin, or 
in the more deep feated parts ; fo that it 
fliould not in any cafe be omitted. 

In violent fp rains the pain is often fo 
feyere, as to induce quicknefs of pulfe 
and other fymptoms of fever. In fuch 
cafes, along with local blood-letting, it is 
fometimes neceffary to take blood from 
fome of the larger vefTels. Opiates be- 
come neceffary, together with all the re- 
medies that prove ufeful in fevers arifing 
from inflammation. 

After blood has been freely evacuated 
from a fprained part, the beft application 
that can be ufed for fome days ^ at firft, is 
a folution of faccharum faturni ; and af- 
terwards, when a thickening of the ten- 
dons continues, as fometimes happens 
notwithftanding the utmoft attention, 
pouring warm water upon the part two 
or three times dally, for the fpice of a 
quarter of an hour or fo each time, 
proves often an ufeful remedy. Even 
common fpring water frequently anfwers 
the purpofe ; but it feems to prove more 

pene- 



Sc6t. II. Inflammatory Tumors. 453 

penecrat'ing when llighdy impregnated 
with fea fak : and we have likewife rea- 
fon to think that the warm waters of 
Bath and Buxton are rendered more ef- 
fectual in cafes of this kind by the im- 
pregnations which they contain, than 
they oiherwife would be. 

Along with warm bathing, fridlions 
with emollient applications prove often 
ferviceable in removing this thickening 
of the parts induced by fprains. But in 
order to prove ufeful, they fliould be per- 
iifted in for a confiderable time. 

During the cure of a contufion or of a 
fprain, the injured part fliould be kept as 
much as poflible in an eafy pofture. In eve- 
ry inftance this fhould be attended to: but 
it becomes more particularly proper when 
the pain is more levere than ufual ; an oc- 
currence which we often fuppofe to hap- 
pen from the fibres of fome of the fprain- 
ed tendons being ruptured, and which 
nothing will cure fo readily as the limb 
in which it has happened being kept for 

a 



454 Of Acute or Ch. XXXVIIL 

a confiderable time in a relaxed eafy 
poflure. 

We have already mentioned the warm 
bath as a remedy in fprains. In various 
cafes cold bathing alfo proves fervice- 
able. After fprains have been of feme 
duration, the injured part is apt to con- 
tinue weak and relaxed, even when the 
pain and fwelling are moflly gone. In 
this fituation, cold water being poured 
upon the part from a height, or being 
fuddenly daOied upon it, and repeated 
once or twice daily, will prove more ef- 
feftual in ftrengthening the weakened 
limb than perhaps any other remedy. 
It is for the removal of debility only, 
however, that it Ihould be employed-; 
and there is much reafon to think that it 
has done mifchief when ufed in the more 
early (lages of fprains. While that 
thickening of the tendons and ligaments 
remains, which we have mentioned a- 
bove, and which often proves the moft 
formidable, as well as tlie moft obftinate 
fymptom which accompanies fprains, 

cold 



Sed. n. Inflammatory Tumors. 455 

cold bathing feems to do harm, by ren- 
dering it more firm than it was before, 
while the contrary efFecfl often refults 
from a proper application of warm wa- 
ter. 

A bandage or roller applied over the 

injured parts, as tight as the patient can 
eafily bear it, proves often ufeful in 
fprains. Mj fupporting the relaxed 
parts, it not only prevents pain, but the 
cedematous fwellings alfo, to which 
fprained limbs are often liable. The 
roller Ihould be of flannel, which yields 
more readily than linen to any variety 
in the fize of the limb, and is the moO: 
efFedlual preventative of the rheumatic 
afFedions with which limbs that have 
fufFered much from fprains are liable to 
be attacked. The roller muft be carried 
fpirally upwards from the inferior part 
of the limb, with an equal prefTure on 
every part of it, in order to prevent 
eedema, which might otherwife take 
place. 

SECTION 



456 Of Chronic or Ch. XXXVIII. 



SECTION III. 

Of Chronic or Indolent Tumors. 

THE general charader of this clafs of 
tumors is, that they are flow in their 
progrefs, and not necefTarily attended 
with inflammation. Tumorsof every kind 
may eventually, indeed, induce inflam- 
mation : Thus fwellings, which have long 
remained indolent, by an increafe of 
bulk will often diftend the fkin fo much 
as to become inflamed ; and all the va- 
rieties of hernia, although not necef- 
farily accompanied with this fymptom, 
for they frequently take place with- 
out it, yet they often tend to induce 
it, for reafons too obvious to require 
being mentioned. But in thefe, we con- 
lider inflammation as an accidental oc- 
currence only, and in no way connedled 

with 



Se&. III. Indolent Tumors. 4^7 

with their rife or formation. Of the 
chronic tumors we fhall firft confider the 
encyfted. 

§ I. Of Encyfted Tumors. 

Every tumor might be confidered as 
encyfted, the contencs of which are fur- 
rounded with a bag or cyft, as is the cafe 
with all the variety of herniae and cf hy- 
drocele, as well as with fome other tu- 
mors ; but in common pracflice thofe tu- 
mors only are termed Encyfted that are 
contained in cyfts of a preternatural for- 
mation. In common language, thefe, as 
well as various tumors of the farcomatous 
kind, are termed Wens. 

The different parts of which an ani- 
mal body is compofed, are connedled to- 
gether by a common medium termed the 
Cellular Subftance ; which is fo univer- 
fally diffufed, that it feems to form a very 
confiderable part of every fibre. In a 
ftate of health the cells of this fubftance 
communicate with each other ; and, like 
the large cavities of the body, they are 

Vol. V. G g kept 



458 Of Chronic or Ch. XXXVIII. 

kept foft and moid by a fecretion that 
is conftantly paffing into them by the 
exhalents, and returning from them by 
the abforbents. In fome parts of the 
body this fecretion would appear to be 
entirely of a ferous nature ; while in 
6thers, it confifts evidently of oil or 
fat. 

While the abforption of this fluid is in 
proportion to the quantity exhaled, no 
accumulation will take place: but va- 
rious caufes may concur to deftroy the 
equilibrium ; and in whatever way this 
may be done, if more be fecreted than is 
carried off by the abforbents, a fulnefs or 
fwelling muft necelTarily enfue. Where 
this fuperabundance is of the ferous 
kind, a dropfical fwelling will be produ- 
ced ; when of an oily nature, obefity or 
fatnefs will take place. 

A general dilpofition in the fyftem to 
this kind of accumulation is a frequent 
occurrence; but caufes fometimes occur 
by which colledions are produced in 
particular parts. In a found ftate of the 

eel- 



Seft. in. IndoUnt Tumors. - 459 

cellular fubftance, that natural commu-. 
nication we have mentioned as fubfifting 
between the different cells of it, mu(l nc- 
celfarily prevent any partial or circunr* 
{bribed collection. And accordingly we 
know, that all ferous effafions very rea- 
dily pafs from one part of it to another. 
But this communication may be inter- 
rupted by different caufes, and accumu- 
lation of the natural fluid may take place 
in a particular part. 

We thus account for the formation 
of encyfted tumors ; to which different 
names have been applied, according to 
the conliflence or fuppofed nature of 
their contents. When of the confidence 
of honey, the tumor is termed Meliceris: 
when of a foft cheefy confiftence, or re- 
fembllng dough, it is termed an Athero- 
ma ; and Steatoma, when it is formed of 
fat. 

But it is proper to remark, that there 

are various degrees of confiftence to be 

obferved in each of thele. Thus the 

fteatoma is fometimcs foft like butter, 

G g 2 and 



46o Of Chronic or Ch. XXXVIIL 

and at other times firm like fuet : and the 
fame kind of variety occurs in the con- 
tents of the atheroma and raeliceris, which 
in fome cafes are equal in firninefs to 
new cheefe, and in others are not firmer 
than the thinneft honey. 

The matter forming the fteatomatous 
tumors, we conclude to be from the firfl: 
of an oily or fatty nature ; and that their 
different degrees of confidence will de- 
pend upon the remora of their contents, 
and upon the quantity of the thinner 
parts of them that have been ablbrbed. 
And we think it probable, that the 
atheromatous and melicerous tumors are 
originally formed by a depofition of fe- 
rum, with perhaps a confiderable pro- 
portion of coagulable lymph ; and that 
the degrees of confidence of which we 
find them, will depend upon various 
caufes : Upon the particular quantity of 
coagulable lymph contained in them ; 
upon their being of longer or (horter 
continuance ; and particularly, upon 
their having been inflamed or not ; and 

to 



Sed. III. Indolent Tumors. 461 

to the extent to which the uiflammatiori 
may have proceeded. 

For the niofl part, a pradlkioner ac- 
cuflomed to this branch of bniinefs will 
be able to diilinguiQi pretty exa6tl)l the 
nature of thefe tumors before laying 
them open. Thus, in general, the (tea- 
toma is of a firm confiftence : it is com- 
monly loofe, and rolls more readily than 
the others under the fkin ; and its fur- 
face is apt to be unequal: The athero- 
ma is fbft and compreflible, but no fluc- 
tuation is obferved in it : While, in the 
meliceris, the fladluation of a fluid or thin 
matter is in general very diftindly per- 
ceived. It is proper, however, to re- 
mark, that neither thefe, nor any other 
means of diftindlion, will at all times 
prove fufficient : for in fome cafes the 
fleatoma, inftead of being firmer than the 
others, is confiderably fofter ; infomuch 
that I have met with different inftan- 
ces of the fat of which they are formed, 
fluduating or moving between the fin- 
gers like thin purulent matter ; and 
G g 3 where 



462 Of Chronic or Ch. XXXVIII. 

where accordingly the opinion that was 
previoufly formed of it was commonly 
erroneous. The atheroma and meliceris 
are fornetimes combined in the fame tu- 
mof : One part of it will be evidently of 
a foft pultaceons nature, and contained 
in a feparate cyft or cell from the reft, 
which is probably of nearly the fame de- 
gree of confiftence with purulent mat- 
ter. 'In a few cafes too, the fteatoma is 
conjoined with thele ; but this is not a 
frequent occurrence. 

In judging of the nature of thefe tu- 
mors, fome advantage may be derived 
from attending to their fituation. Thus 
we obfervCj that in fome parts of the 
body, fat is much more apt to be fecre- 
ted and depofited in the cellular fub» 
ftance than in others* In fome parts, 
indeed, fat is fcarcely ever found in 
it ; as is the cafe over a great part of 
the head ; while in others, particularly 
over the prominent part of the abdo- 
men, we commonly meet with it even 
in the leaneft fubjecfls. Now I be- 
lieve 



Se£t. III. Indolent Tumors^ 463 

lieve it will be obferved, that the fteato- 
matous tumors are feldom, if ever, met 
with in thofe parts of the body which 
are not ufually in a ftate of health fup- 
plied with fat : at leaft this has been fo 
uniformly the cafe in the courfe of my 
pradice, that I have never met with an 
inftance of it ; and it tends much to con- 
firm the idea which 1 have endeavoured 
to eftabhfh of the formation of thefc 
tumors. The head, as I have obferved, 
is very fparingly fupplied with fat, at 
the fame time that we find it more lia- 
ble than any part of the body to en- 
cyfted tumors; but they are very uni- 
verfally of the atheromatous or melice- 
rous kinds *. Nor have 1 ever met with 
the fteatomatous tumor but where fat is 
ufually depofited in the contiguous cel- 
G g 4 lular 



* By Atheromatous and Melicerous, I mean to exprcfs dif- 
ferent degrees of confiftence of a curdy pultaceous matter. By 
fome, the firmer kinds of this have been miftaken for and de- 
fcribed as the contents of the fteatomatous tumor ; but they 
will be found to be in every refpeft different from the fatty fub- 
ftance contained in the real fteatoma. 



4$4 Of Chronic or Ch. XXXVlti. 

lular fubdance. They are rarely indeed 
obferved on that part of the body which, 
we have juft obferved, is plentifully fuppli- 
ed with fat. We feldom meet either with 
thefe or any other variety of encyfted 
tumor on the abdomen ; and at firft view 
this may be confidered as an objedlion 
to our theory : On farther attention, 
however, it will rather appear to fup- 
port it. The parietes of the abdomen 
being formed of foft yielding parts, with 
no bone or hard body beneath, we may 
readily fuppofe that they will be little, if 
at all, afFeded by any ordinary preflure : 
fo that this caufe of obftrudion will not 
here have the fame effed as it evidently 
has on the head and other parts where 
the cellular fubftance lies immediately 
contiguous to bone. 

All the tumors of the encyfted kind 
are fmall at firft, and increafe by very 
flow degrees. They arc of very diffe- 
rent ftiapes and fizes : In feme they re- 
femble a walnut ; on the head they are 
commonly round and fmooth, and do 

not 



Seft. III. Indolent Tumors. 465 

not ofcen arrive at any great bulk ; but 
in other parts of the body they are often 
of very irregular forms, at the fame time 
that they are more apt to acquire more 
confiderable degrees of bulk. I have met 
with fteatomatous tumors weighing up- 
wards of twenty pounds ; and they are 
fometimes double this weight. They 
are never at firft attended with pain ; 
and the fkin for a confiderable time re- 
tains its natural colour. But when they 
become large, the veins of the fkin, as 
well as thofe of the fac, become large 
and varicofe ; and the prominent part of 
the tumor acquires a clear fliining red 
colour, fimilar to that which accompa- 
nies inflammation : but it feems to be 
different from this, as it is feldom at- 
tended with pain, excepting it be inju- 
red by external violence. In this fitua- 
tion, indeed, a blow or a bruife will rea- 
dily excite inflammation, by which the 
fkin will become tender and painful, and 
by which it will foon be made to crack 
or burfl, if it be not prevented by the 

con- 



465 Of Chnnic or Ch. XXXVIH. 

contents of the tumor being difcharged 
by an operation. 

This is the ordinary progrefs of thefe 
tumors : But it is proper to remark, that 
although they never advance quickly, 
yet in fome fituations they terminate 
much fooner than in others, and without 
arriving at the fame degrees of magni- 
tude. Thus, in the head they do not 
ufually become bigger than a large -egg. 
In a few cafes, indeed, they are larger ; 
but for the mod part they terminate be- 
fore they acquire this fize, by the tegu- 
ments becoming tcnfe and thin, and even 
burfting if they be not prevented in the 
manner we have mentioned. But on 
other parts of the body, particularly on 
the back, on the fhoulders, and thighs, 
the teguments will fometimes retain 
their natural apppearance long after a tu- 
mor has acquired a very great bulk. — 
This feems to proceed from a greater or 
lefTer degree of laxity in the ikin. In 
the head, the teguments are firmer, and 
do not yield fo readily to diftention as in 

other 



Seft. III. Indolent Tumors* 467 

other parts of the body ; by which any 
tumors lying beneath them muft necella- 
rily be more quickly brought to a pe- 
riod. 

This circumftance of fituation has 
likewife a conliderable effedl on the 
firmnefs with whic tumors are attached 
to the contiguous parts. In fbme fitua- 
tions they are fo loofe and moveable, 
efpecially while they continue fmall, 
that they readily yield even' to flight de- 
grees of preflure : but in others, particu- 
larly when they are covered with any 
fibres of mufcles, they are fometimes ve- 
ry firmly fixed from their commence- 
ment. The attachment of tumors is al- 
io mucli influenced by their remaining 
free of inflammation, or their being to a 
greater or lefl^er degree attacked with it j 
for they never become inflamed, even in 
the flightefl: manner, without fome degree 
of adhefion being produced between the 
cyfts and correfponding teguments. 

In the treatment of encyfted tumors, 
we arc direded by authors to attempt 

the 



468 Of Chronic or Ch. XXXVIII, 

the cure in the firft place by refolution ; 
and if this fails, by extirpation. With 
a view to accomplilh a cure by refolu- 
tion, fridlions with mercurial ointments 
are recommended, together with gum- 
plaflers, and a variety of other applica- 
tions. No praditioner, however, of the 
prefent age, will depend upon this ma- 
nagement ; nor will he exped to be, able 
to remove thefe tumors in any other way 
than by the afllftance of furgery. 

We fliall therefore fuppofe that the re- 
moval of one of them by an operation is 
agreed upon : The next point to be de- 
termined is the mode of efFeding it; 
and this in a great meafure fhould de- 
pend upon the contents of the fac. If 
they appear to be of the thin melicerous 
kind, which for the mofl part will be 
the cafe if a diHind fluduation be difco- 
vered through the whole body of the 
tumor, it ought to be treated like a com- 
mon abfcefs. In the fmaller colledions, 
the matter may be difcharged by laying 
the teguments and cyfl open in the mofl 

de- 



SeQ:. III. Tndoknt 7umors: ^5g 

depending part of the tumor with a 
common lancet, and treating it in the 
ordinary way till it fills up or adheres 
from the bottom : But in large fwellinn-s 
of this kind, as a free admidion being 
given to the air proves always hurtful, 
the opening ought to be made in a man- 
ner the lead apt to be attended widi this 
inconvenience. In a former publica- 
tion, we have recommended the pafiing 
of a feton or cord through large abfcefles 
as the beft method of opening them ; 
and as the fame method may with equal 
propriety be employed in thofe encyfted 
tumors which are formed by colletlions 
of thin matter, we ftiali refer to what 
was then faid upon the fubjefl *. We 
fhall jufl; obferve, that the cord fliould 
pafs through the whole extent of tiie tu- 
mor, from the fuperior part of it to the 
mod depending point; and that the in- 
ferior opening at which it paffes our 
fhould be fufficiently large for admitting 
the matter to be very freely difcharged. 

In 

* Vide Treatife on Ulcers, &c. Part I, 



470 Of Chronic or Ch. XXXVIIL 

In this manner I have had many in- 
ftances of large encyfted tumors being 
healed with much more eafe than ahiioft 
ever happens under the ordinary method 
of treatment. Several years ago, I gave 
my opinion upon this point at confider- 
able length in the publication above al- 
luded to; and farther experience of the 
advantages which refult Irpni ithastend- 
<;d much to confirm it. ^ 

This method of cure, however, is on«^ 
ly applicable where the contents of tu-^ 
mors are fo thin as to be eafily difchar- 
ged by a fmall opening. When they arc 
tto firm to admit of this, they muft ci- 
ther be emptied by an extenfive opening 
into the cyft, or the cyft with its content^ 
niufl be dilFeded out. 

Where a cyft containing matter ad- 
heres fo firmly to the contiguous parts 
as to require much time to remove it by 
diflcdion, it (hould never be attempted. 
It will be fufficient to lay it freely open 
through its whole extent by an incifion, 
and to remove any loofe portion of it. 

The 



Sed. Ill, Indolent Tumors. 471 

The contents of the tumor will in this 
manner be completely removed : and the 
cure may either be efFe<5led in the ufual 
way, by preferving the wound open till 
it fills up with granulations from the 
bottom ; or it may be attempted by 
drawing the divided edgeh of the fkin to- 
gether, and trufting to moderate prefTure 
and the ordinary efFeds of inflammation 
for producing a complete reunion. I 
have fucceeded in both ways ; and I 
think it neceflary to obferve, that both 
are equally certain, when a confiderable 
part of a cyft is left, as when the whole 
is carefully diOTeded off in the ufual man- 
ner. To thofe who are accuflpmed to 
think that it is necelTary to remove the 
cyfts of thefe tumors entirely, it will at 
firft appear to be unfafe to allow any 
part of them to remain : Experience, 
however, will foon convince them that 
it may be done with fafety. In com- 
mon practice the removal of the cyft is 
always advifed ; but where it is to be at- 
tempted, it is better to open the cyft by 



472 Of Chronic or Ch. XXXVIIT. 

a longitudinal cut through the whole tu- 
mor than to remove it entire. When the 
cyft is empty, it is more readily laid hold 
of with the fingers or forceps, and more 
eafily diflecfled out, than \vhen the bag 
remains full and diflended. 

When the bag is thus removed, the 
teguments fhould be laid together and 
retained with adhefive plafters, or with 
two or three futures, as the opera- 
tor may incline : and if an equal pref- 
fure be made over the whole, a cure 
may thus be obtained by the firft inten- 
tion. In every part of the body this is 
an objedl of importance, as it tends to 
fhorten the cure ; but it is particularly 
proper in the face and other external parts 
of the body, where the cicatrix produced 
by a tedious fore proves frequently very 
unfeemly. 

The arteries which fupply the cyfts of 
thefe tumors are fomecimes fo large as 
to pour out much blood when they are 
cut. In this cafe, they fhould be imme- 
diately fecured with ligatures : and if 

the 



Seel. III. Indolent Tumors. 473 

the threads be left of fuch a length as to 
hang out at the lips of the wound, they 
prove no obftacle to the cure being com- 
pleted in the manner we have,diredled ; 
for when they are applied with the te- 
naculum, as they ought to be, they may 
be drawn away with eafe and fafety at 
the end of the fecond or third dreffing. 
By an ill-timed caution, fome pracflition- 
ers, from an apprehenfion that ligatures 
in fuch circumftances may do harm, have 
advifed that none of the arteries which 
appear in the removal of thefe tumors 
fliould be tied. Nay, fome have gone fo 
far as to fay, that it is feldom or never 
necefTary to apply ligatures to fuch arte- 
ries as are cut in the removal of fclr- 
rhous breads : Rut as I have known dif- 
ferent inftances of patients dying fud- 
denly from lofs of blood where this pre- 
caution was neglected, and as I never 
met with a (ingle cafe of any harm 
having been done by attending to it, I 
"would advife every artery to be fecu- 
red that does not flop immediately oa 
Vol. V. H h being 



474 Of Chronic or Ch. XXXVIII. 

being divided. Belides the real dan- 
ger which fometimes occurs from this 
being negleded, the very intention of 
healing the fore without the formation 
of matter is apt to be fruftrated by it. — 
In the removal of cancerous breads, 
where the edges of th« divided £kin have 
been drawn together iio as to cover the 
fore, by the burlling of an artery which 
had not been fecured, fuch a quantity of 
blood has been efFufed between the tegu- 
ments and parts beneath, as has either 
prevented them from uniting, or has ren- 
dered it neceffary to remove the bandages,, 
and to lay the parts again open in order 
to difcover the bleeding vefTel. Of this 
I have met with different inftances ; and 
every practitioner of experience mull pro- 
bably have done the fame. 

In tumors of an ordinary fize, there is 
never any neceflity for removing any part 
of the fkin. By a fingle incifion along the 
courfe of the tumor, in the manner we 
have direded, the fac will either be fuf- 
iiciently opened, or it may be removed 

with 



Seft. III. Indolent Tumors, 475 

with equal eafe as if in were opened by a 
crucial incilioii ; and although the fkia 
may at fiiil appear to be too ex.teniive, 
yet in the courfe of a fliort fpace of time 
it will contrai^t fo as merely to cover the 
parts beneath. But in very extenlive tu- 
mors, where the fkin is fo much dillend- 
ed as to give caufe to imagine that ic 
will be much puckered if part of it be 
not removed, it will be better to take 
away fome portion of it. This will be 
bed effected by two femilunar cuts in- 
cluding as much of the fkin as ought to 
be taken away ; and this being done, 
the portion of fkin thus ieparated mufl 
be removed along with the cyfl. And 
in the fame manner, when we are ope- 
rating upon a tumor where the promi- 
nent part of the fkin is either ulcerated, 
or rendered fo thin by diftention that we 
cannot with propriety attempt to fave it, 
fuch parts of it as are thus affected muft 
be included between two femilunar cuts, 
and removed in the manner we have 
mentioned. In other refped:s, the cure 
H h 2 muft 



^47^ Of Chronic or Ch.XXXVIIL 

mufl: be conduced as if none of the fkin 
were taken away, by drawing the divi- 
ded edges of the teguments together, 
and endeavouring to make them unite 
by the firrt: intention in the manner we 
have advifed. 

Where the tumor is fo large as to ren- 
der it proper to remove any part of the 
fkin, we are defired by Ibme practitioners 
to do it with cauflic ; and by others 
cauftic is ufed for opening every tumor. 
The only inftance, however, in which 
cauftic (hould be employed, is where pa- 
tients are fo timid that they will not fub- 
mit to the ufe of the fealpel. 



^ 2. Of Ganglions. 

. By the term Ganglion we here mean 

an indolent moveable tumor which forms 

upon the tendons in different parts of 

the body, but mod frequently on the 

back part of the hand and joint of the 

wriU. 

TumoFS 



Sefl:. III. Indolent Tumors. 477 

Tumors of this kind when prefled upon 
are found to poflefs a confiderable degree 
of elafticity ; by which they may in gene- 
ral be diftinguifhed from the encyfted tu- 
mors defcribed in the laft fe6lion. They 
feldom arrive at any great bulk ; they 
are not often attended with pain ; and 
for the moft part the (kin retains its na- 
tural appearance. On being laid open, 
they are found to contain a tQugh, vif- 
cid, tranfparent fluid, refembling the 
white of an egg. 

It feldom happens that tumors of this 
kind become (b large as to render them 
obje61:s of furgery : and when duly at- 
tended to on their firft appearance, they 
may often be removed entirely, either by 
moderate fridion frequently repeated, 
or gentle compreffion applied to them 
by means of thin plates of lead or any 
other pliable metal. In this manner, 
they are more readily difcuffed than any 
other kind of fwelling : but neither the 
friction nor the preflTure fliould be car- 
ried too far, otherwife the fkin may be 
H h 3 iQ 



47§ ' <y Chronic or Ch. XXXYIIL 

fo much fretted as to give rife to inflr'.m- 
itiation ; by which fiippnration, and ab- 
fceffes dlliiciijt of cure, may be indu- 
ced. 

When this method of removing a gan- 
glion does not fucceed, nothing farther 
flionldbe attempted as long as the tu- 
inor remains of a fmall fize : But when 
it becomes io large as to prove trouble- 
fome, eitljer by impeding the motion of 
a joint, or in any other manner, it ought 
to be removed by excifion, in the fame 
manner as we have advifed in the treat- 
ment of encyfled tumors when the cyft 
is to be taken entirely away ; that is, by 
making a longitudinal cut through the 
teguments over the whole extent of the 
tumor ; and after feparating the fkin 
from it on each fide, to dilfert it off 
from the tendon; Or, when it is found 
to adhere fo firmly to the contiguous 
parts as to render this impradicable, an 
incifion may be made into it of iuch a 
depth as to difcharge the contents of it, 

whei> 



Se£l. III. Indolent Tumors, 479 

when a cure may be effi?'iled by prefer- 
ving the wound open till it fills up with 
granulations from the bottom. 

In general, praditioners arc averfe to 
operate in tumors of this kind, on the 
fuppofition of the wound being difficult 
to heal ; but I have feldom known this to 
be the cafe. 



§ 3. Of Swellings of the Burfa Mucofa. 

The burfae mucofae are fmall membra- 
nous bags feated upon, or very contigu- 
ous to the different large joints. They 
naturally contain a thin, tranfparent, ge- 
latinous fluid, which feems to be intend- 
ed for lubricating the parts upon which 
the tendons move that pafs over the joints. 
They are met with in other parts of the 
body, but chiefly about the hip-joint, 
that of the knee, ankle, ihoulder, elbow, 
and wrift *. 

H h 4 In 

* I am happy at having it in my power to anr 

n ounce 



48o Of Chronic or Ch. XXXVIll. 

I 

In a ftate of health, the fluid contain- 
ed in-thefe burfse or facs is in fuch fmall 
quantity, that it cannot be difcovered till 
they are laid open by difledion : But in 
feme cafes it accumulates to fuch an ex- 
tent as to produce tumors of a confider- 
cble fize. This is not an unfrequent ef- 
fedl of contufions and fprains ; and I 
have often met with it as a confequence 
of rheumatifm. The fwelling is feldom 
attended with much pain : it yields to 
prefTure, but is more elaflic than where 
ordinary matter is contained : at iirft it 
is always confined to one part of the 
joint ; but in fome cafes the quantity of 
accumulated fluid becomes fo confider- 
able as nearly to furround the joint. — - 
The ikin always retains its natural ap- 
pearance, unlefs it be attacked with in- 
flammation. 

The contents of thefe tumors are found 

tp 

ronnce to the public, that a defcription of all the burfaj mu- 
cofae which have yet been difcovered, with an account of the 
difeafes to which they are liable, will foon be publiihed by 
Dr Monro. 



SeGt. III. Indoleni Tumors, 481 

-to be of different kinds : and this variety 
feems to depend on the caufe by which 
the fwelling is produced ; a circumftance 
which merits particular attention. Thus 
when a fwelling of this kind is induced 
by rheumatifm, the contents of the tu- 
mor are commonly thin and altogether 
fluid, refembling the fynovia of the dif- 
ferent joints ; at lead this has been the 
cafe in any of thofe which I have known 
opened : While in fuch as proceed from 
fprains, there is ufually found mixed 
with this tranfparent fluid, a confider- 
able quantity of fmall firm concretions. 
In a few cafes I have met with thefe con- 
cretions of a fofter texture, fo as to be 
eafily compreffed between the fingers ; 
but in general they are too firm to ad- 
mit of this. We may commonly, how- 
ever, judge of this by the kind of fludlu- 
ation which is difcovered in the tumor : 
when the concretions are foft, the fluc- 
tuation is ufually diftind ; but when 
they are firm, it is not fo clearly percei- 
ved, and they are eafily felt beneath the 

fingers 



482 Of Chronic or Ch. XXXVIII. 

fingers on being prefTed from one part of 
the fac to another. 

In pradlice it will be found to be an 
objed of importance to be able to di- 
ftinguifh between thofe colledions which 
proceed from rheumatifm, and fuch as 
are the confequences of old fprains : For 
in the former, I believe, it will be feldom 
neceflary to propofe any operation ; as in 
moft inftances, perhaps in all, the fwell- 
ing will difappear in courfe of time, 
merely by keeping the parts warm 
with flannel ; by frequent fri6lions ; by 
warm water being frequently pumped 
upon them ; or by the application of 
blifters. At leart this has happened 
in almoft every rheumatic cafe of this 
kind in which I have been concerned. — 
But in thofe fwellings of the burfae mu- 
cofae, which originate from fprains, al- 
though the quantity of efFufed fluid may 
remain ftationary, it will feldom, if ever, 
difappear entirely. In fuch cafes, there- 
fore, when the tumor arrives at fuch a 
fize as to prove troublefome, we are un- 

I der 



Sea.III. Indolent Tumors. 483 

der the neceHlty of propofing an opera- 
tion for removing it. 

The only operation that is admiflible, 
is the opening the fac, fo as to difcharge 
the matter contained in it, and to pre- 
ferve the wound open till it fills np with 
granulations from the bottom. In moft 
fituations this may be done with fafety ; 
but in fome parts, particularly about the 
joint of the wrifl, thefe collections are 
fo covered with tendons that a good deal 
of caution and attention is required in 
the treatment of them. When it is found 
that the contiguity of tendons prevents 
the fac from being opened to fuch an ex- 
tent as may probably enfure a cure, it 
will be better to lay it open at each end ; 
and after prclling out the contents to 
pafs a fm a 11 feton or cord from one 
opening to the other. In this manner a 
flight degree of inflammation will be ex- 
cited on the infide of the fac, when the 
cord may be withdrawn, fo as to admit 
of a cure being attempted by gentle 
prciFure, applied with a roller over the 

courfe 



484 Of Chronic or Ch. XXlC-VIII. 

courfe of the tumor. I have fometimes 
fucceeded hi diis way, when a cure could 
not be obtained by any other means ; and 
when the cord is cautioufly introduced 
with a blunt probe, no harm occurs from 
it, even when it pafles beneath fome of 
the tendons. The cord, however, (hould 
not be continued fo long as to induce 
any great degree of inflammation; for in 
the neighbourhood of large joints this 
might prove alarming : And we know 
from experience, that even a flight de- 
gree of inflammation anfwers the pur- 
pofe fufliciently. 

A confiderable degree of fliffnefs com- 
monly remains upon that part of the 
joint where the tumor was fituated. 
The moft efFed:ual remedy for this, is 
frequent friftions with emollients, and a 
proper application of warm fleams to the 
part affe(fled. 



§4.0/" 



Sed. III. Indolent Tumors. 485 



§ 4. Of Colledions within the Capful ar Ligaments 
of foints. 

Collections of various kinds are met 
with in the capfular ligaments of joints. 
Blood may be efFufed within them. In- 
flammation is here, as in other parts, 
frequently fucceeded by the formation of 
matter ; and ferous effiifions occur In 
them, forming what are commonly term- 
ed Dropfical Swellings of the joints. 

Swellings of this kind fhould be dl- 
ftingulQied with as much precifion as 
poflible. They are mod apt to be con- 
founded with colle(5lions in the burlae 
mucofsE, or with matter effufed in the 
cellular fubflance covering the joints. 
From the fird of thefe they may in, 
general be diftinguiflied, by the con- 
tained fluid palling with freedom from 
one fide of the joint to the other ; 
and from its being diffufed over the 
whole of it : Whereas, when it is con- 
tained 



486 Of Chronic or Ch. XXXVIII. 

talned in one of the burfe, the tumor is 
more circamfcribed ; being for the moft 
part fixed above or upon one fide of the 
joint. And in thcfe there is feldom any 
great degree of pain ; while collections 
of every kind within the capfular liga- 
ments are apt to be painful. 

They are more eafiiy dilTmguiflied 
from matter colle<fled in the cellular fub- 
ftance covering the joints. In the lall, 
the collection is evidently very fuperfi- 
cial ; and it is not fo much confined to 
the joint itfelf, being in general found 
to extend in every direction farther than 
the boundaries of the capfular liga- 
ments. 

We judge of the nature of the fluid 
collected in thefe fwellings by the cir- 
cumftances which have preceded them, 
as well as by the fymptoms with which 
they are accompanied. When a violent 
bruife of a joint is immediately fucceed- 
ed by a large effufion within the capfu- 
lar ligament, it will probably be found 
to confift chiefly of blood. This Is not 

a 



Se£t. Ill, Indolent Tumors. 487 

a frequent occurrence ; but as I met 
with a remarkable inftance of it in one 
cafe, I conclude that it may happen in 
others. 

When inflammation of a joint termi- 
nates in effufion within the capfular 
ligament, there will be reafon to ima- 
gine that the matter forming the tumour 
is of a thin ferous kind, with fome ten- 
dency to purulency: for well-condition- 
ed pus is feldom met with in ligamen- 
tous or membranous parts. And laftly, 
when coUedlions within the capfular li- 
gaments fucceed to rheumatic affedions, 
there will be much reafon to fuppofe that 
they are entirely ferous ; for we know 
that thefe eflPufions which take place in 
rheumatifm are very commonly of this 
kind. 

The importance of our being able to 
diftinguiih the nature of the matter con- 
tained in thefe fwellings, becomes obvi- 
ous from the different pradlice which 
they require : As the making an opening 
into a large joint is always hazardous, 

from 



488 Of Chronic or Ch. XXXVIII. 

from the pain and inflammation which 
it is apt to excite, it fliould never be at- 
tempted but in cafes of neceility. One 
of the caufes which in general are fup- 
pofed to require it, is matter colietSled 
within the capfular Hgaments : But when 
by experience we difcover that a par- 
ticular kind of matter may be allowed 
to remain in this fituation without any 
detriment, we rather allow it to lodge, 
than to incur the rifle which often en- 
fues from letting it out. Now this is 
uniformly the cafe with thofe effufions 
which we have mentioned as the confe- 
quences of rheumatifm. Whether they 
be colledled in the burfae mucofse, as 
mentioned in the lafl: fedlion, or within 
the capfular ligament of a joint, they 
fliould never be laid open. Of what- 
ever fize they may be, they will ve- 
ry commonly be difcufled by the re- 
medies we have mentioned, namely, 
by fndlions : the pouring of warm wa- 
ter upon the parts affe(fled ; by proper co- 
vering with flannel ; and the ufe of bli- 
fters ; or, when thefe fail, fupporting the 

tumefied 



Se€t. III. Indolent Tumors. 489 

tumefied parts with a laced (locking, or 
with a roller, applied withfnch a dt^i:GC of 
tightnefs as the patient can eafiiy bear, 
will often prove fuccefsfnl. But whether 
we are able to diffipate the fwelling en- 
tirely or not, when we are convinced that 
it is of the rheumatic kind, no opening 
fhould be made into it. Tiie patient may 
continue to complain of Ibme uneafinels 
and ftlffnefs in the joint, but this will al- 
ways be trifling when compared with the 
pain and inflammation which may occur 
from laying it open. But when matter is 
collccled in the cavities of joints, which 
may do mifchief by lodging, or which 
does not readily admit of ablbrptlon, an 
opening fliould be made for dlfcharging 
it. The matter which forms in confe- 
quence of high degrees of inflammation, 
and eftuled blood, are of this kind. 
Blood is indeed frequently extravafiited 
among fofc parts without much detri- 
ment ; but when in contafi with carti- 
lage or bone, it foon hurts them materi- 
ally ; and the fame effeft follows from 
Vol. V. I i the 



490 Of Chronic or Ch. XXXVIIL 

the lodgment of matter formed by in- 
flammation. 

The danger which attends this opera- 
tion, feems to depend in a great meafure 
upon air fi nding admifiion to the ca- 
vity of the joint ; it ought, therefore, to 
be done in fuch a manner as may moft 
effedually prevent this occurrence. For 
this purpofe the opening (hould be made 
with a trocar ; and if the fkin be previ- 
oufly drawn tight to the upper part of 
the tumor, by pulling it down immedi- 
ately on withdrawing the canula after 
all the fluid is evacuated, the rifk of air 
being admitted will thus be lefTened. 
A piece of adhefive plafler fhould be 
direaiy laid over the opening in the 
ikin ; and the whole joint fhould be 
firmly fupported, either with a laced 
■ flocking, or a flannel roller properly ap- 

plied round it. 

As a farther preventative of bad con- 
fequences from this operation, if the pa- 
tient be plethoric, he (hould be blooded 
to fuch an extent as his ilrength will 

bear: 



Seft. lUp Indolent Tumors. 49} 

bear : He lliould be put upon a ftricfl 
antiphlogiftic regimen ; and in every re- 
fpe6l fliould be managed with caution: 
for inflammation being very apt to enfue 
from it, we cannot be coo much on our 
guard againft it. 



§ 5. Of Concretions arid preternatural Excrefcence( 
within the Capfular Ligaments of Joints. 

We fometimes find joints become 
painful, and their motion much impe- 
ded, by the preternatural formation of 
different llibltances w^ithin the capfu- 
lar ligaments. In fome cafes they are 
fmall loofe bodies, of a firmnefs equal to 
that of cartilage ; and in others ihey are 
of a foft membranous nature, fprouting 
from an eroded furface of one of the 
bones forming the joint, or from the in- 
ner furface of the capfular ligament. 

In Ibme cafes, thefe fubilanccs remain 

always in nearly the fame lituatlon, 

without being much affected either by 

I i 2 prefRire 



492 Of Chronic or Ch. XXXVIII. 

prefTure or by the motion of the joint ; 
particularly in the foft membranous kinds 
of them, which are in fome degree fixed 
by their attachments. But the others, 
which have nearly the firmnefs of carti- 
lage, are commonly fo moveable, that 
their fituation is altered by the leaft de- 
gree of motion ; and they flip fo eafily 
on being touched, that it is difficult to 
fix them even with the fingers. 

In the former, which remain fixed nearly 
to the fame fituation, the pain is conftant, 
but it is feldom fevere ; whereas in the 
latter, it is only felt in particular fitua- 
tions, perhaps when the conneding mem- 
brane pafTes between the ends of the bones : 
but in thefe cafes it proves often fo ex- 
cruciating as to be altogether infupport- 
able. I have known different inftances 
of this, where in fome particular po- 
llures of the leg, for it is in the knee in 
which thefe concretions feem chiefly to 
occur, the pain became fuddenly fo ex- 
quifite as to induce fainting. And 
where this returns frequently, the pa- 
tient 



Sed. III. Indolent Tumors. 49^ 

tient is io much afraid of it, that he 
choofes rather to avoid walking almoft 
entirely than to run any rifk of indu* 
cing it. Nay, in fome cafes, I have 
known the patient roufed from the mofl 
profound fleep, by the limb being merely 
moved when in bed. 

As thefe fubftances are of a nature 
which will probably for ever refift the 
powers of every medicine, and as they 
can only be removed by the joint being 
laid open, the queftion to be determined 
is, Whether this ought to be attempted 
or not ? Many fpeak of this as an opera- 
tion attended with fo Httle rifk, that 
pradlitioners are apt to advife it in every 
cafe where the pain induced by the dif* 
eafe is in any degree fevere. In two 
cafes, indeed, which fell under my own 
management, the joints of the knee were 
laid open ; the foreign bodies ^vere re- 
moved ; and the wounds healed almoft 
With the fame eafe, as might have been 
expeded in fimilar injuries in any other 
part of the body. But fince that period, 
lis dif- 



4^4 Of Chronic ot Ch.XXXVIIf. 

different inftances have occurred wliefc 
tliis operation induced the rhoft alarm- 
ing fymptoms ; . which even terminated 
in fuch a manner as to render it necef^ 
fary to amputate the limb. I never ob* 
ferved indeed fuch high degrees of in- 
flammation from any other caufe ; nei- 
ther is it confined to the joint itfelf. The 
whole limb, both aVove and below the 
wound, becomes (liiT and fwelled in a 
remarkable degree, with a painful in-* 
fiammatory tenfion, extending from one 
end of it to the other. 

The uncertain fuccefs of this opera-^ 
tion may make Us doubtful in every 
inftance of advifing it. The follow- 
ing is the opinion I have formed on 
this point, drawn from a good deal 
of experience in cafes of this kind. 
Where concretions formed within the 
capfular* ligaments of joints appear, up- 
on examination with the fingers, to be 
perfectly loofe and detached, if the pain 
which they excite is very fevere, rather 
than fubmit to a long continuance of it, 

w© 



S<i£t. III. Indolent Tumor's. 495 

we fhould venture in a cautious manner 
to take them out, by making an incifion 
into the joint : But wherever there is 
much rcafon to fufpecH; that they are 
conneded with any part of the joint, the 
patient fhould rather be advifed to fub- 
mit to the pain which they induce, which 
in general will be rendered moderate by 
avoiding exercife, than to run the rifk at- 
tending the extirpation of them. 

The pain indeed, even in a retired life, 
may fometimes become infupportable. 
In this cafe I would advife the amputa- 
tion of the limb. The remedy is no 
doubt fevere ; but it is lefs painful, as 
well as lefs hazardous, than the excifion 
of any of thofe concretions have ever, 
proved that have been attached to the 
capfular ligaments. 

The opening into the capfular liga- 
ment for the removal of thefe looie bo- 
dies, may be made in the following man- 
ner : If it is the joint of the knee or 
ankle that is to be opened, the patient 
fliould be laid upon a table or on a bed ; 
114 but 



496 Of Chronic or Ch. XXXVIIL 

but if any of the joints of the arm are to 
be opened, he may be allowed to fit ; 
only, in whatever poflure he may be, the 
limb fhould be fecured in the firmeft 
manner by afliftants, in that poflure 
which admits of the body to be taken 
out being felt in the mofl diftind man- 
ner. On this being done, the furgeon 
fhonld endeavour to fix it with the fin- 
gers of his left hand towards the upper 
part of the joint, after an afliftant has 
been defired to draw the Ikin as much as 
poflible upwards from the part where 
the incifion is intended to be made. 
The furgeon, with a fcalpel in his right 
hand, is now to make an incifion thro 
the tegumfents and capfular ligament, 
diredlly upon the fubftance itfelf, of fuch 
a fize as will admit of its being eafily ta- 
ken out ; which may be done either with 
the point of one of the fingers, or with 
the end of a blunt probe pafled in beneath 
it. If it is found to be connedled by 
any fmall filaments, either to the capfu- 
lar ligament or to the cartilages of the 

joint. 



Sed. III. Indolent Tumors: 497 

joint, they Ihould be cautioufly divided, 
either with a probe- pointed biftoury or 
probe-pointed fciffirs, after drawing the 
fubftance itfelf as far out as it can be got, 
with fmall pointed forceps, or with a 
Iharp hook when it is of a texture that ad- 
mits of a hook being ufed. When more 
concretions than one are found, they 
fhould all be taken out at the fame 
opening when this can be done : but 
when they lie on oppofite fides of the 
joint, two openings will be neceflary ; 
only in this cafe it will be better to al- 
low the firft incifion to heal before at- 
tempting the fecond, fo as to avoid as 
much as poflible the exciting of inflam- 
mation. 

After the concretion is removed, the 
fldn fhould be immediately drawn over 
the wound in the capfular ligament ; and 
the lips of the opening in the fkin being 
laid together, they fhould be fecured in 
this fituation by pieces of adhefive pla- 
fter, fo as to prevent the air from find- 
ing accefs to the cavity of the joint. 

Till 



498 Of Chronic or Ch. XXXVUI. 

Till the wound be completely healed, the 
patient flaould not only be confined to 
bed, but the limb fliould be kept as much 
as pofiible in one pofture ; and a ftridl 
antiphlogiftic regimen fhould be obferved. 
But for the farther management of fuch 
cafes, and of the fymptoms with which 
they are apt to be attended, we muft re- 
fer toChap. XXXVI. Seaion VIII. on the 
fubjecft of Won.nds in the Ligaments. 

We have defired, that in making the 
incifion into the capfular ligament, it 
may be done at the upper part of the 
joint. The intention of this is to pre- 
vent the fynovia, after the fkin is drawn 
over the opening in the ligament, from 
finding fuch ready accefs as it otherwife 
would do to lodge in the cellular mem- 
brane immediately beneath the fkin ; a 
precaution that is eafily attended to, and 
from which fome advantage may be de- 
rived. 



S6. 



Se£l. III. Indolent Tumoi-s. 459 



^ 6. Of Ana/ana or Oedema. 

The terms Anafarca and Oedema are 
applied to that variety of dropfical fwel- 
ling where the water is colledled, not in 
any diftindl cavity, but in the cellular 
fubftance. The part is generally cold^ 
and of a pale colour ; and being poffef^ 
/ed of little or no elafticity, it retains the 
mark of the finger when prelTed upon. 

In general, fwellings of this kind are 
connedted with fome general affedlion of 
the fyftem j but in fome cafes they oc- 
cur in particular parts, from caufes 
which affed thefe parts only. Thus, legs 
or arms which have been much weaken- 
ed by contufions or fprains are apt to be- 
come oedematous. Tumors preffing up- 
on any of the larger lymphatics are apt 
to induce them. And they fometimes 
occur from the lymphatics of a limb be- 
ing cut, either by accident or by fome 
chirurgical operation. 

In 



500 Of Chronic or Ch. XXXVIII. 

In the treatment of thefe fwellings, 
this circumftance of their being general 
or local requires particular attention. 
When they are induced by tumors pref- 
fing upon the lymphatics, the removal 
of thefe tumors will alone effedl a cure. 
And when weaknefs of a limb, in confe- 
quence of fprains or contufions, feems to 
be the caufe of them, the beft method of 
cure will be to fupport the weakened 
parts either with a laced flocking or a 
flannel roller, to prevent their yielding 
to diftention, till in courfe of time, and 
by the efFeds of cold bathing and mode- 
rate fridlions, they recover their natural 
(tone. 

But in thofe anafarcous fwellings of 
the feet and legs which take place as a 
fymptom of general dropfy, we muft not 
venture upon removing or preventing 
them by compreffion ; for if the ferum 
be prevented from falling down to the 
legs, it will be apt to fix upon parts of 
more importance. In thefe cafes, we 
truft to the general tendency in the. fy- 

ftem 



Se£b. III. Indolent Tumors. 501 

fletn being removed by proper msdl- 
cines, for obtaining a complete cure: 
But when the fwelling becomes confider- 
able, we have it in our power to procure 
a temporary relief, by difcharging the 
water by fmall pundlures made through 
the fkin into the cellular membrane, 
which will often empty the fwelling of 
a whole limb. The relief which this 
procures is often fo confiderable, that we 
ought to advife it more early in the dif- 
eafe than isj commonly done. I: will 
feldom have any material efFedl on the 
cure of the difeafe ; but befides the pre- 
fent dafe v/hich it gives, it prevents that 
lofs of tone which the cellular fubflance 
muft fuffer, and which muft always be 
detrimental where anafarcous fwellings 
are permitted to go to fuch a height as 
they often do. 

In general the water is difcharged by 
incifions inftead of pundlures : But fmail 
pundlures made with the point of- a lan- 
cet anfwer the purpofe better : they give 
a fufficient vent to the v/ater, at the fame 

time 



502 Of Chronic or Ch. XXXVIII. 

time that they are not fo apt to inflame 
and mortify. But as we had occafion 
to fpeak of this v/hen treating of the 
Anafarcous Hydrocele in Chapter VI. 
Section II. we fhall refer to what was 
then faid upon ic. 

Where the fwelHng is induced by any 
of the lymphatic vefTels of a limb being 
cut, as fometimes happens in extirpating 
indurated glands from the arm-pit, fmall 
pun6lures made in the under part of the 
limb afford immediate relief; while little 
advantage is derived from any other re- 
medy. 



S 7' Of the Spina Bifida. 

The term Spina Bifida is applied to 
thofe fmall foft fwellings which fome- 
times appear in the courfe of the fpine 
in new-born children, mod frequently 
at the inferior part of it, between the 
two laft vertebrae of the loins. A fluc- 
tuation is diflin<5lly perceived in them : 

and 



Se£l. III. Indolent Tumors. 503 

and the fluid which they contain can In 
fome meafure be prefled in at an opening 
which takes place between the fpinous 
procefles of tlie two vertebrse on which 
they are feated. In fome cafes this 
opening is found on diffecSlilon to proceed 
from a natural deficiency of bone ; in 
others, from the fpinous procefTes of the 
yertet)ra? being merely feparated from 
each pther : in all of them, the difeafe 
proceeds from ferum colleded within 
the natural coverings of the fpinal mar- 
row. In a few cafes it is connected 
with hydrocephalus ; but this 15 not com- 
mon. For the moft fart it is a local af- 
fedion. 

This is perhaps one of the mofl fatal 
difeafes to which infancy is liable ; for 
as yet no remedy has been difcovered for 
it. In fome cafes, however, children la- 
bouring under it have lived for two or 
three years ; but in general they linger 
and die in the fpace of a few months. 
All the affiftance that art has hitherto 
been able to afford, is to fupport the 

•tumor 



504 Of Chronic or Ch. XXXVIIL 

tumor by gentle prefTure, with a propet 
bandage. In this manner it has for fome 
time been prevented from increafing, by 
which life has been protraded ; but this 
is all that we have yet been able to do. 

It has fometimes unfortunately hap- 
pened, where the nature of thefe tumors 
has not been underftood, that they have 
been laid open with a view to difcharge 
the fluid contained in them. Experience 
fhows, however, that every attempt of 
this kind fhould be avoided j for hither- 
to the pradice has uniformly proved un- 
fuccefstul. The patient has either died 
fuddenly, or in th? courfe of a few hours 
after the operation. 

If conjedture may at any time be in- 
dulged, and proposals for innovation 
mentioned, it muft furely be allowable 
in cafes hopelefs as the one we are now 
confidering. If the fwelling in the 
fpina bifida be produced by real dif- 
eafe fubfifting in the veffels of the fpinal 
marrow, or in thofe of its membranes, it 
is not probable that any remedy will 

ever 



Sed. III. Indolent Tumors. 505 

ever be difcovered that will remove it : 
But if the opening between the fpinous 
procefTes of the vertebra; with which 
it is always accompanied, be not the 
effe6l of the difeafe, as it is common- 
ly fuppofed to be, and if the want of 
fiipport, which this deficiency of bone 
muft create to the membranes of the fpi- 
nal marrow, be the caufe of lerbus effu- 
fions within thefe membranes, might not 
fome advantage be derived from apply- 
ing a ligature round the bafe of the tu- 
mor, not merely with a view to remove 
it, but alfo to draw the bottom of the 
cyft fo clofely together, that it may acft 
as a proper lupport to the parts beneath ? 
Whether any benefit may be derived 
from it or not, is no doubt very uncer- 
tain : But in a difeafe which we know 
will otherwife terminate fatally, we are 
warranted in propofing whatever can af- 
ford even the fmallefl chance of fafetv ; 
fo that I mean to attempt it in the firfb 
cafe of this kind that falls under my 
care. After applying a ligature as clofe- 
VoL. V. K k \y 



5o6 Of Chronic or Ch. XXXVIII. 

ly as poHible to the bafe of tlie tumor, 
and as foon as the tumor itfelf has fallen 
off, I would propofe to apply a firm-ftuf- 
fed pad, (imilar to that of a rupture-trufs, 
to the opening between the vertebra: ; 
and by means of a proper bandage, to 
fecure it with fuch a degree of tightnefs 
as may ferve to fupport the parts with- 
in. 

Whether or not this method may in any 
cafe effe6> a cure is uncertain; but it ap- 
pears to be the moft probable one of pro- 
longing life : for wherever the tumor has 
been opened, death feems to have enfued 
more by the removal of fupport from the 
contained parts than from any other 
caufe. Now, no method of treatment 
we could advife would fo readily com- 
prefs the parts within, and at the fame 
lime remove the tumor. 

The tumor termed Spina Bifida occurs, 
as we have already obfer.ved, in different 
part&of the fpine; but a fwelling of per- 
haps tlie fame nature is fometimes met 
^a'ith on different parts of the head. A 

tumor 



Sed. III. Indolent Tumors. 507 

tumor is obferved at birth ; and on exa- 
mination, it is found to be formed by a 
fluid lodged beneath the membranes of 
the brain, which have been forced out 
at iome unoffified part of the fkull. In 
fome cafes the fwelHng remains ftation- 
ary for a great length of time ; but for 
the mofl: part it becomes quickly larger, 
and at lafl terminates in death. Hither- 
to the fame efFe<5l has refulted from lay- 
ing this kind of tumor open, as was men- 
tioned to occur in cafes of fpina bifida.— 
The patient has commonly died in a few- 
hours after the operation. 



§ 8. 0/" Schrophulous Tumors. 

In a former publication, when treat- 
ing of the Scrophulous Ulcer, we offer- 
ed fome general obfervations upon fcro- 
phulous tumors. We (hall now, there- 
fore, refer to what was then faid, and at 
prefent advert to the method of treating 
them. It is not the cure of the fcrophu- 
K k 2 lous 



5o8 Of Chronic or Ch. XXXVIII. 

lous conflitution which we mean to con- 
fider : This fubjecfl belongs more to the 
province of medicine. 

The firfl queftion that occurs in the 
chiruigical treatment of a fcrophulous 
tumor is, Whether we fhould endeavour 
to promote the fuppuration of it or not, 
by means of poultices and other external 
applications \ For a confiderable time I 
adopted this practice in the freeft man- 
ner, of applying warm poultices and fo- 
mentations to every tumor of this kind ;. 
but by experience I was at laft convin- 
ced of its ineiBcacy. Nay, I now think, 
that it often does harm : for fcrophulous 
tumors being formed of matter which is 
not convertible into pus, poultices and 
other warm applications have little efFe<5l 
in bringing them forward ; and when 
long ufed, they weaken and relax the 
parts fo much, that the fores which en- 
fue are more difEcult of cure than when 
poultices are not employed. In every 
fcrophulous fore, the .parts are apt to re- 
jnain long foft and fpongy, by which 

they 



Sed:, III. Indolent Tumors. 509 

they are prevented from healing. The 
effefl of thefe emollient relaxing applica- 
tions is to increafe this tendency to fbft- 
nefs to a degree which otten proves pre- 
judicial. 

As I know of no application which in 
the real fcrophulous tumor ever proves 
ufeful, either in retarding its progrefs or 
in bringing it forward, I now advife even 
every covering to be laid afide, unlefs 
the patient wifhes to prevent the fwel- 
ling from being feen ; in which cafe he 
is defired to cover it in the manner that 
is moft agreeable to himfelf. But as I 
do not obferve that expofure to the air 
does harm, and as in fome cafes I have 
thought that this expofure of the tumor 
renders the fubfequent fores more eafy 
to cure, I would prefer this mode of 
treatment w^henever it can be done with 
propriety. Even the external applica- 
tion of hemlock, which in the form of 
poultices is often advifed in fcrophulous 
tumors as a difcutient, fhould be laid 
afide. In fcrophulous fores, I have ob- 
K k 3 ferved 



5IO Of Chronic or Ch. XXXVIIT. 

ferved fome advantage derived both from 
the internal exhibition and outward ap- 
plication of hemlock : but although 
I have often known it ufed in tumors 
of this kind, I cannot fay that it was 
ever produdlive of any benefit. The 
only remedy I have ever known to adl 
with any apparent efficacy in prevent- 
ing fcrophulous tumors from coming 
forward, has been a long continued ufe 
of the cold bath, particularly of fea-ba- 
thing, and of mineral waters, efpeciaily 
thofe of Moffat ; but in order to produce 
any effedl, they fhould be begun early in 
the difeafe, while the tumors are fmall, 
and long perfifted in. Indeed, as foon as 
it becomes fufficiently obvious that a pa- 
tient is attacked with fcrophula, 1 would 
advife him, whenever it can be done, to 
refort to fuch a fituation where one or 
other of thefe remedies can be employ- 
ed with perhaps little interruption for 
feveral years together. In what man- 
ner the drinking of thefe mineral waters, 
PV even of fea- water, operates in prevent-? 



Sect. III. Indolent Tumors, c 1 1 

ing the formation of tumors in fcrophu- 
lous patients, will be diflicult to deter-- 
mine: But it feems to be probable, that 
cold bathing proves chiefly ufeful by in- 
vigorating the fyftem at large, and parti- ' 
cularly the lymphatic fyftem, which in 
fcrophuia appears to be remarkably weak 
and relaxed. 

The next queflion to be determined 
with refpevft to fcrophulous tumors is, 
when they have become foft, and even 
full of matter, whether they Qiould be 
opened, or allowed to burft of them- 
felves ? This (hould in a great meafure 
be determined by their fit nation. When 
they are feated upon any of the large 
joints, or upon the cavities of the thorax 
or abdomen, as there might be a rifk of 
the matter burfling into them, it ought 
certainly to be difcharged by a free 
opening made with a. lancet or fcalpel ; 
or in very large colledlions, where it 
might prove hurtful to expofe the cavity 
of an extenfive abfcefs to the air, it may 
be done with more fafety with a trocar, 
K k 4 or 



512 Of Chronic or Ch. XXXVIII. 

or by pafTing a feton or cord through it. 
But where the tumors are fo fituated 
that no harm can arife from the matter 
remaining in them, it is better that they 
fhould be allowed to break of themfelves : 
for even when they are managed in the 
mod judicious manner, the fores which 
enfue will prove tedious and difBcuIt to 
cure, whde a fear will be the confe- 
•quence whether the tumor has been 
opened or not ; and the patient and his 
friends, from ignorance of the nature of 
the difeafe, as well as from other mo- 
tives, are apt to blame any opening that 
is made, as the caufe either of a tedious 
cure, or of an unfeemly mark. As an 
additional reafon for this pradice, I be- 
lieve It will be found, that fores which 
enfue from fcrophulous tumors will for 
the moft part heal more kindly when al- 
lowed to burft than when they are open- 
ed. 

I have only to obferve farther, that tu- 
mors of a fcrophulous nature are fome- 
times jnet with, which frpm inadver- 
tency 



Sedl. III. Indolent Tumors. 513 

tency are apt to be miftaken for thofe of 
the real fcirrhous kind. And there is 
caufe to fufpe(fl that miftakes of this kind 
have tended t<)raife the reputation of dif- 
ferent medicines, particularly of cicuta, 
as well as to have been the caufe of the 
extirpation of tumors, which ought not 
to have been touched. When fcrophulous 
tumors are deeply feated, they have com- 
monly a degree of firmnefs which they 
do not poffefs in the more external parts ; 
and when they are in a fufpicious Situa- 
tion, as in the glandular part of a wo- 
man's breaft, they are apt t8 be miftaken 
on a flight examination for fwellings of 
a bad nature. But a moderate degree of 
attention will always prevent miftakes of 
this kind : Even the firmeft kind of the 
fcrophulous tumor is foft and com- 
preflible when compared With the real 
fcirrhus : It is always of a fmooth equal 
furface ; it is feldom in its early ftages 
attended with pain ; and for the moft 
part limilar affeiftions appear in other 
parts ot the body ; whereas the real fcir- 
rhus 



514 Of Chronic or Ch, XXSVIII. 

rhus *is always fomewhat unequal or 
knotty : Although it does not for a con- 
fiderable thue become uniformly pain- 
ful, a dinging difagreeable pain is com- 
monly felt in it from time to time, even 
from its firft appearance ; and it is not 
neceflarily connefted with fymptoms of 
fcrophula. 



§ 9. 0/" Bronchocele, 

Every tujnor of an indolent nature 
occupying the fore-part of the neck, is in. 
common practice termed a Bronchocele. 
In the Englifh language we have no pre- 
cife denomination for it. In French 
this difeafe is termed Goitre. 

Swellings in this fituation would with 
more propriety be termed Tracheacele: 
But with a view to prevent confuflon, 
we think it better to retain that api-tlla- 
tion under which they have commonly 
been defcribed. 

Authors mention different difeafes un- 
der 



3e6t. III. Indolent Tumors. 515 

der this denomination : Some contend- 
ing, that the term Bronchocele fhouJd 
be confined to one variety of tumor ; and 
others, that it may be applied to fwellings 
oi very different kinds. Difputes of this 
nature, however, anfwer no good par- 
pole ; and as pradtical obfervations are 
the chief obje(5ls of this work, I think ic 
better to mention the varieties of the dif- 
eaie, which I have either feen, or which 
have been accurately defcribed by au- 
thors, with the treatment fnited to each, 
than to enter the lifts of controverfy upon 
this fuhjedl. 

I. The fore-part of the neck, like every 
part of the body fupplied with large 
arteries, is liable to fwellings of the aneu- 
rifmal kind. They do not frequently oc- 
cur in this fituation, but inftances of them 
are fometimes met with. 

This variety of the difeafe may be di- 
ftinguifhed by all the ordinary fymptoms 
of aneurifm : But its appearing luddenly 
After lome violent exertion, particularly 

in 



5i6 Of Chronic or Ch. XXXVIII. 

in coughing or laughing ; by its being 
foft and compreiTible from the firft ; by 
the tumor being at firft feated diredlly 
on the courfe of one of the carotid arte- 
ries ; by the pulfe in the advanced ftages 
of the difeafe being evidently affected by 
it, fo as to become intermittent ; and by 
a ftrong pulfation being difcovered thro' 
the whole extent of the tumor. 

2. Encyfted tumors, particularly thofe 
of the meiicerous kind, are frequently 
met with on the courfe of the trachea. — 
They are chara(5lerifed by the fame fymp- 
toms in this fituation by which they are 
marked in other parts of the body : They 
are foft and comprefTible ; the fluctua- 
tion of a fluid is evident upon prelTure ', 
although they are always fmall at firft, 
they frequently become fo extenfive, as 
to extend from one ear to another ; and 
the fkin ufually retains its natural ap- 
pearance to the laft. The feat of this va- 
riety of the difeafe is evidently in the cel- 
lular membrane. 

3. Inftances have occurred of tumors 

form- 



Se£t. III. Indolent Tumors. 517 

forming in this ficuacion, by the lining 
membrane of the trachea being forced 
out between two of the cartilages by vio- 
lent fits of fneezing, coughing, or laugh- 
ing. In this cafe the fwelling will at 
firft be fmail ; and although foft and com- 
prefTible, no fludluation will be perceived 
in it. 

4. The lymphatic glands of the neck 
have in fome cafes of fcrophula become 
fo fwelled, as to produce tumors of con- 
fiderable magnitude over the whole 
courfe of the trachea. They are diftin- 
guiihed by the fymptoms which ufually 
accompany fcrophulous fwellings. 

5. The thyroid gland has in fome in- 
ftances been known to fwell to a great 
bulk, fo as to induce tumors of an enor- 
mous fize, extending from each fide of 
the trachea to the angle of the corre- 
fponding jaw. In this variety of the 
difeafe, the fwelling is at firft foft; but 
no fluduation is perceived in it j the fkin 
retains its natural appearance ; and no 
pain takes place in it : But as the tumor 

ad- 



51 8 Of Chronic or Ch. XXXVIIL 

advances in fize, it becomes unequally 
hard ; being firm or elallic in fome parts, 
and perfedly foft in others : The fkin 
acquires a copper colour, and the veins 
of the neck become varicofe ; and in this 
ftate of the difeafe the face becomes flufli- 
ed, and the patient complains of frequent 
head-achs, as v^rell as of flinging pains 
through the body of the tumor. 

This is mentioned by authors as that 
variety of the difeafe which occurs fo 
frequently among the inhabitants of the 
Alps and other mountainous countries, 
and which in general is fuppofed to ori- 
o-inate from the ufe of fnow-water. 

6. Whatever may be the nature of 
thofe varieties of bronchocele which oc- 
cur in other kingdoms, I have reafon to 
believe, that in this country it does not 
fo frequently proceed from fwellings of 
the thyroid gland as is commonly ima- 
gined. At leaft in two cafes of broncho- 
cele, the only ones where I had an op- 
portunity of difcovering the feat of the 
dileaie by diffedion, although it was 

firmly 



Se6t. III. Indolent Tumors. 515 

firmly believed in boLh of them that 
the fvvelling originated in the thyroid 
gland, yet, on laying the parts open, it 
was found to be much otherwife. This 
gland, inftead of being increafed, feemed 
evidently diniiniflied by the compreflion 
produced by the tumor ; and the fwell- 
ing itfelf was chiefly formed of a con- 
denfed cellular fubftance, with effufions 
in different parts of it of a vifcid brown 
matter. In one cafe the tumor was 
chiefly fixed on one fide of the neck ; 
but in the other it occupied both fides, 
and reached from one ear to the other, 
and from the fternum to the chin. In 
both cafes the fwelling fubfifted for a 
great number of years ; and in one of 
them the patient died at laft of another 
difeafe. At firft they had no other ap* 
pearancc than might be expeded from 
a natural increafe in the parts lying con- 
tiguous to the trachea ; they were foft 
and compreflible ; but no fiuduation was 
perceived in them, and the fkin retained 
its natural colour : But as they increafed 

in 



520 0/ Chronic or Ch. XXXVIII. 

in fize, they likewife became firmer ; for 
although at laft a fofcnefs, and even a 
flu(ftuation, was difcovered in different 
parts of them, yet the principal part of 
the tumor continued hard, while others 
had a pecuHar fpringinefs or elallicity, 
iimilar to that of a tin canifter : The 
veins on the furface of the tumors be- 
came turgid ; and the face of a livid co- 
lour, evidently from the blood being im- 
peded in its courfe from the head. In 
one cale, the patient complained of much 
giddinels: In both, the breathing was 
much obftruded ; and the patient, who 
died of the difeafe, feemed to fuffer chief- 
ly from this circumftance. 

Thefe are the varieties of bronchocele, 
for which one method of treatment can- 
not be applicable. And hence appears 
the abfurdity of fpecifics for this difeafe, 
fuch as calcined egg-(hells, propofed and 
recommended by authors : for although 
a medicine may be ufeful in one, yet it 
cannot prove fo in all the varieties of 
it. 

In 



Sc£l. Ill, Indolent Tumors, jil 

In the aneurlfiiial bronchocele, the 
treatment fuited to aneurifm in general 
niufl be obferved. To feciire either of the 
carotid arteries with a ligature, will no 
doubt be confidered as a hazardous ope- 
ration : But here there is no alternative ; 
whether it be a true or a falfe aneurifm, 
death 'will enfue if it be not prevented 
by this operation. This chance, there- 
fore, ought always to be given ; as in o- 
tlier cafes of aneurifm the artery fliould 
be tied both above and below the affect- 
ed part. 

In cafes of bronchocele produced by 
encyfted tumors upon the trachea, what 
we have faid upon the treatment of thefe 
tumors in general will prove applicable. 
While they are fmall, the cyfls with their 
contents may be removed in the manner 
we have mentioned: And even in the 
mod enlarged (late of them, we need not 
defpair of being able to afford effedlual 
relief. When they are of the (leatoma- 
tous kind, confilting of real fat, however 
large they may be, we may with pro- 

'VoL. V. L 1 priety 



522 Of Chronit or Ch. XXX Vip, 

priety attempt to remove them : for in 
almoft every inftance, the conne<^Vion of 
tumors of this dei'cription with the con- 
tiguous parts is lb flight, that they are 
removed with eafe. The veflels on the 
furface of the tumor may be enlarged j 
but thefe will be chiefly veins, and they 
may be eaOly avoided. In tumors con* 
fifling entirely of fat, I have never feeu 
any of the arteries of fuch a fize as to 
be pfodudive of any diflurbance ; they 
are always fiiiall, and are eafily fecured 
by comprellion when they lie beyond the 
reach of ligatures. 

When, again j the coritetits of the fwell- 
irtg are fluid, they may be difcharged ei- 
ther by an incifion with a fcalpel, or by 
pafling a feton or cord through the cyft; 
Snd when the contained matter is of a 
pultaccous confiftcnce, forming what is 
termed an Atheroma, it mufl be difchar- 
ged by a large opening in the mod de- 
pending part of the tumor. 

Where the tumor is formed by a her- 
nia of the lining membrane of the tra- 
chea. 



Se£t. III. Indolent Xumors. 523 

chea, gentle compreflion is the only re- 
medy to be depended on ; and all fuch • 
exertions fhonld be avoided as mighc 
have any influence in producing it; par- 
ticularly violent laughter, fneezing, 
couching, and crying. In fcrophulous 
fwellings of this kind, we muft depend 
chiefly on thofe remedies which prove 
mofl: ufeful in other fcrophulous afFec- 
tions : and with a view to remove the 
compreilion produced upon the trachea, 
as well as upon the veins returning from 
the head, the contents of the tumors 
ftioald be difcharged as foon as they are 
found to be in any degree fluid. 

In that variety of the difeafe which 
originates from a tumefadion of the thy- 
roid gland, frequent frictions prove ufe- 
ful, particularly when employed early, be- 
fore the fwelling has become large ; and 
faponaceous and mercurial plafters have 
in fome cafes appeared to prove fervice- 
able. Pra(^icioners, however, are leldom 
confulted in that ftage of the difeafe in 
which remedies of this kind may be ufe» 
L I 2 fully 



524 Of Chronli or Ch. XXJCVIIL 

fully applied : For as the fwelllng does not 
. often occalion uaeafinefs at firfl, it is (el- 
dorn aieiitioned by the patient till it has 
fubfifled for fonie tirtie. In the enlarged 
{late of this gland, I do not fiippofe that 
any remedy will ever be found powerful 
enough to dlfcufs it ; fo that the only 
qaeftions we have to determine are, whe- 
ther or not we fliould attempt to remove 
the tumor by an operation ? and whether 
it fliould be done with caufilc or t^ie 
fcalpel ? 

We know that this gland is very plen- 
tifally fupplied with blood, and that the 
arteries which belong to it are ufually 
much enlarged in the difeafe we are now 
confidering. This, together with the con- 
tiguity of the thyroid gland to the carotid 
arteries, which in this enlarged flate of 
that gland are even apt to be comprcfTed 
by itj renders the extirpation of it in art 
advanced period of the difeafe extremely 
hazardous. For the arteries are of fuch 
a magnitude as to pour out a great deal 
of blood in a fhort fpace of time ; while 

they 



Se£t. III. Indolent Tumors. 5^jj 

they lie at fuch a depth in this enlarged 
flate of the parts, that they cannot be 
eafily laid hold of with ligatures, nor can 
much comprejiion be applied to them 
from their^ fituation with refpedl to the 
trachea. I therefore conclude, that, 
when tumors of this defcriptioa have ac- 
quired any confiderable bulk, it would 
not be advifable to run the hazard of at- 
tempting to remove them with the knife, 
and that the patient fhould rather truft 
to the treatment ufually employed in fuch 
cafes for palliating the fymptoms as they 
occur *. And although we are informed, 
L 1 3 that 



Mr Gooch relates a cafe, where in an attennpt to re- 
move a broncbocele by excifion, fuch profufe hemor- 
rhagy took plnce, that the operator, although very intre- 
pid, was obl'ged to defifl before the operation v>'as half 
finifhed. No means that were employed could put a 
total (lop to the blood ; and the patient died in lefs than 
a week. 

Another cafe had very nearly terminated fatally ; and 
the patient's life was only preferved by Iiaviiig a fuccef- 
fion cf perfons to keep a conftar:t preflTure upon the 
bleeding veffels, day and night for near a week, with their 
fingers on proper comprefles, after the operator had 

been 



526 Of Chronic or " Ch. XXXVIIL 

that in this fituation the potential, and 
even the adlual cauteries have been em- 
ployed with advantage, yet the pradlice 
has not become fo general as to make it 
probable that it has ever been fuccefsful ; 
nor can we, from what we have learned, 
prefume to recommend i^ in any ftage 
of this diforder. 

But although the reafons we have men- 
tioned appear to be fufficient for deter- 
ring us from attempting the removal of 
thefe tumors in any way when they are 
much enlarged J yet while the gland is 
not much increafed ; when fri(5lions and 
other remedies fail ; and when the dif- 
eafe is continuing to advance ; I think 
any pradlitioner would be warranted in 
advifing it to be removed by excifion '• 
for in this early period of the difeafe, the 
difficulty of fecuring the arteries with H- 
gatures will be much lefs than it is found 
to be in the more advanced ftages of it : 

been repeatedly difappointed in the ufe of the needle 
and ligature.— Vide GOoch's Medical and Chirurgrcal Obfer^- 
vations, p. 136. 



Se£t. III. Indolent Tumors. 



in 



at IcAft the rifk occuring from this will be 
inconiiderable, when compared with thai 
which will probably enfue from the tykr- 
mor being allowed to remain. 

In the fixth and laft variety of the dif- 
eafe which we have mentioned, fri<fltions 
with mercurial ointment have in the 
fif (I ftages of it appeared to prove fer- 
viceable. And in one cafe the progrefs 
of the tumor was evidently retarded by 
repeated blifters ; but the patient going to 
a diftance, they were negleifled, and at 
laft it arrived at a very enormous fize. 
In this ftate I faw him at the diftance of 
feveral years, but I did not learn in what 
manner the cafe terminated. I have rear 
fon to think, however, from the appear- 
ance of the Iwelhng, both at its com- 
mencement and in its more advanced 
ftages, that it proceeded from an effufion 
into the cellular fubftance of the neck, 
attended with that condenfed ftate of 
this fubftance which was dilcovered by 
dilTedion in the two cafes mentioned 
above. 

L 1 4 But 



.52^ Of Chronic or Ch. XXXVIII. 

But however ferviceable blifters, as 
well as other remedies, might prove in 
the early flages of the difeafe, no ad- 
vantage can be expecfled from them when 
the tumor has acquired any great bulk* 
In this fituation palliatives only fhould 
be employed ; for the baiis of the fwell- 
ing ufually runs lo deep, that it could 
not be removed but with the utmoft ha- 
, 2ard J and it is not probable that any 
advantage would be derived from laying 
it open 3 for, a confiderable part of it 
being firm and folid, the fize of the tu- 
mor would not be much diminifhed by 
the difcharge which might be procured, 
while the fore that would enfue might 
degenerate into cancer, 

§ 10. Of Navi Materni, 

By Nsevi Materni are meant thofe 
marks which we frequently find in dif- 
ferent parts of the body at birth ; and 
which are fuppofed to originate from im- 

preffions 



Se£t. III. Indolent Tumors. 529 

preffions made on the mind of the mo- 
ther during pregnancy. They are of ya- 
rious forms, being frequently found to 
refemble ftrawberries and cherries, and 
in other inftances grapes, figs, pears, 8cc, 
Their colour is various ; but for the moD: 
part they are of a deep red, refembling' 
the colour of claret or red port. 

Many of thefe marks are perfedly flat, 
and never rife above the level of the 
fkin ; and as they are not painful, they 
never in this ftate become the objedls of 
furgery. But in fome cafes they appear 
from the firft: in the form of fmall pro- 
tuberances, which frequently increafe To 
quickly as to arrive at great degrees of 
bulk in the courfe of a few months. I 
once faw a tumor of this kind in a child 
of a year old of the fize of a goofe's egg, 
which at birth was not larger than a 
pea. 

No fladluation is difcovered in thefc 
tumors ; on the contrary, they feel to be 
firm and flelhy. In foms cafes they are 
pendulous, and hang by flender attach- 
ments 



530 Of Chrome or Ch. X^XVllL 

ments to the contiguous parts ; but for 
the tnofl: part they are fixed by broad 
cxtenfive bafes. 

Various remedies have been recom- 
mended for, the removal of thefe excrefcen- 
ces ; and in ancient times different charms 
were propofed for them. The myftery 
proceeding from this is perhaps one reai* 
fon of the general averfion which ftill 
prevails againft any attempt being made 
to remove them. But fo far as I have 
feen, no greater danger attends the re- 
moval of thefe fwellings than the extir- 
pation of any other tumor of the farco- 
matous kind. They arc fupplied indeed 
more plentifully than other tumors with 
blood ; for in many inftances they ap- 
pear to be entirely formed by a congeries 
of fmall blood-veflels ; but the arteries 
which go to them are in general eafily 
fecured with ligatures. It is proper, 
however, to remark, that the operation 
fliould never be long delayed : for as the 
fize of the veffels depends upon that of 
the tumor, they fometimes becor(ie fo 

large 



Sefl:. III. Indolent Tumors. 53 r 

large as to throw out a good deal of 
blood before they can be fecured ; fo 
that the operation fhould always be pro- 
pofed as foon as it is obferved that the 
tumor, inftead of remaining ftationary, 
acquires a greater bulk. 

The operation is of a very firaple na- 
ture. The tumor, with all the difcolour- 
ed fkin, is to be difledled oflFwIth a fcal- 
pel ; and the arteries being fecured, the 
edges of the remaining fkin fl^iould be 
drawn together, and kept in this fitua- 
tion either with adhefive plafters or fu- 
tures : Or, when they cannot be drawn 
completely together, they may at lead 
be made to cover a confiderable part of 
the fore ; by which the cure will be much 
iliortened, and the cicatrix leflened. In 
this cafe, that part of the fore which is 
left uncovered muft be treated like a 
wound from any other caufe. 

It is fcarcely necefTary to mention, 
that where the tumor is pendulous, and 
connedled to the parts beneath by a nar- 
row neck only, it fljould be removed by 

tying 



533 Of Chronic or Ch. XXXVIIL 

tying a ligature round it of a degree of 
tightnefs fufficient for putting an imme- 
diate flop CO the circuUtion through the 
whole of it. 

% 11. Of Warts. 

Warts are indolent, fmall, hard, co- 
lourlefs excrefcences, which appear on 
different parts of. the body, but chiefly 
on the fingers and hands. They take 
their rife from the cutis and cuticle. 
They occur at every period of life, but 
more, frequently in infancy than in old 
age. 

When from their fize or fituation warts 
do not prove troublefome, they fhould 
not be touched ; for generally in courfe 
of time they either fall off or wafl:e gra- 
dually away. But fometimes warts are 
fo large and fo fituated that we are un- 
der the neceflity of employing means for 
removing them. 

When they are pendulous, and have 

narrow 



ScS. III. Indolent Tumors. 533 

narrow necks, the eafieft method of ta- 
king them away is with ligatures : for 
this purpofe a hair is fometimes ufed, 
but a fine thread is preferable. But 
when their bafes are broad, we remove 
them either with the fcalpel or with ef- 
charotic applications. There are few 
patients, however, who will fubmit to the 
fcalpel ; and as we feldom fail with ef- 
charotics, they are generally employ- 
ed. 

The lunar cauflic, or lapis infernalis, 
are the flrongefl applications of this 
kind ; but warts commonly become ve- 
ry painful after being two or three times 
rubbed with them. The fame objedion 
takes place to a folution of quicklilver 
in aquafortis, otherwife it proves a very 
powerful efcharotic. Mercury difTolved 
in an equal quantity, or even in double 
its weight, of ftrong fpirit of nitre, is a 
remedy that will not fail in removing 
warts of every kind ; but as it is apt to 
fpread, it fliould be ufed with much 
caution. Pulvis* fabinse being daily ap- 
plied 



534 Of Chronic or Ch. XXXVIH. 

plied to warts, will for the moft part re- 
move them in the courfe of two or three 
weeks ; but this likewife is apt to induce 
inflammation. The beft application I 
have tried is crude fal ammoniac : It afls 
flovvly, but induces neither inflammation 
nor pain ; and excepting in the very 
harder kind of warts, it feldom fails in 
removing them. They fhould be well 
rubbed two or three times daily with a 
piece of the fait previoufly moiilened in 
water. Liquified fait of tartar fome- 
times anfwers the purpofe ; and I have 
known fpirit of hartlhorn prove fuccefs- 
ful. 

Warts frequently appear upon the pe- 
nis as a fymptom in venereal affedions, 
and as they are nearly of the fame nature 
with thofe we have been confidering, the 
fame method of treatment will apply to 
them. In general, the tendency in the 
fyftem to produce them does not conti- 
nue long ; and if the parts be kept clean, 
they will at laft begin to decay, and go 
entirely off whether any application be 

made 



Sedt. III. Indolent Tumors, 535" 

made to them or not. But as patients 
are always anxious to get free of them, 
pra(5litioners are often induced to make 
trial of remedies which fhould be avoid- 
ed : For till this tendency to their for- 
mation is removed, they rile almoft as 
quickly as they are rubbed off. Nor 
has mercury any good effedl here : I have 
known different mercurial courfes advi- 
fed for the removal of warts ; but they 
have never produced any advantage, and 
they very commonly do harm. When 
we have reafon to fuppofe that every o- 
ther lymptom of the difeafe is eradica- 
ted, the continuance of warts Ihould be 
no inducement to the exhibition of more 
mercury. When they are tender on the 
furface, and produce matter, as is fome- 
times the cafe, walhing them morning and 
evening in lime-water, or in a weak fola- 
tion of faccharum laturni, will commonly 
remove this ; and at lalt they will difap- 
pear in the manner we have mentioned. 
But when this delay will not be agreed 
to, one or other of the efcharotics men- 
tioned 



53^ Of Chronic or , Ch. XXXVIII. 

tioned above mufl: be employed ; or if 
the patient confents to their being remo- 
ved with the fcalpel, the parts from 
whence they are cut may be touched 
with lunar jcauftic, in order to prevent 
them, with as much certainty as pofTible, 
from returning. 

It is proper to remark, that in the 
treatment of warts of every kind, we 
fliould be cautious in avoiding every ap- 
plication which we have once obferved 
to excite inflammation ; for this fymp- 
tom, when it arrives at any height, is 
difficult to remove. For the fame rea- 
fon, when a \yart is to be removed with 
the fcalpel, we fliould rather encroach a 
little upon the foupd fkin, than run any 
ri(k of injuring the wart itfelf, or of lea- 
ving any part of it. By want of atten- 
tion to this precaution, I have known 
the mofl: formidable fymptoms induced 
by what at firft: appeared to be fuch a 
trifling excrefcence, as not to deferve no- 
tice. In one cafe, indeed, fuch a pain- , 
ful obllinate fore enfued on the Ugt from 

the 



SeOi. III. Indole7it Tumors. ^^7 

the removal of a fmall wart, that ampu- 
tation of the limb was rendered necef- 
fary, in order to fave the life of the pa- 
tient. 



§ 12. Of Flefhy Excrefcences, 

No part of the body is altogether ex- 
empted from the formation of flefhy tu- 
mors or excrefcences. They differ fronj 
warts in being fofter, and in their be- 
ing apt to become large. They are fel- 
dom painful. In general they are fome- 
what more red than the fkin in natural 
health ; and for the moft part they 
have a firmnefs of conliflence refem- 
bling that of the lips. When laid open, 
they have at firrt fight nearly the fame 
appearance with a piece of mufcular 
fubltance newiy divided ; but on far- 
ther examination, no fibres can be difco-- 
vered in them. They feem to confift 
chiefly of cellular lubllance, wicli a great 

Vol. V. M m prp* 



53S Of Chronic or Ch. XXXVIII. 

proportion of blood-veffels infinitely ra- 
mified. 

In the treatment of thefe tumors, no 
external applications are found to have 
any good effedl. Efcharotics hav6 fome- 
times been employed for removing them ; 
but they feldom prove effectual, and they 
are very apt 'to irritate and excite in- 
flammation. Whenever it is determined, 
therefore, to remove a tumor of this 
kind, it fhould either be done with a li- 
gature, or with the fcalpel. "When the 
neck is narrow, the method by ligature 
fliould be preferred ; but when the at-^ 
tachment to the parts beneath is broad, 
this is inadmilTible. When the fcalpel is 
employed, care fhould be taken that no 
part of the tumor be left ; and the edges 
of the divided fkin fliould be drawn fa 
together, as to cover as much of the re- 
maining fore as can with propriety be 
done. When any part of it does not 
heal by the firft intention, it mufl be 
treated like a wound produced in any 
other manner. 

% 12- 



Sed. III. Indolent Tumors, 539 



§ 13. (y Corns, 

Corns are fmall hard tubercles, which 
occur on different parts of the body, par- 
ticularly on the toes and foles of the feet. 
In foine cafes they appear to be of a horny 
inorganic nature. But in others, it is 
evident that they are fupplied both with 
blood-vcffels and nerves, from their be- 
ing painful, and difcharging blood oa 
being cut. For the mofl: part they are 
feated in the fkin : but in fome inftances 
they pafs to fuch a depth as to reach the 
periofteum ; by which much pain and 
fwelling are apt to occur on the conti- 
guous parts. This is more efpecially apt 
to happen when they are feated upon 
any of the joints, or upon parts thinly 
covered with flefh. 

The beft preventative of corns, is the 
wearing of wide fhoes, and avoiding every 
kind of prefTure: and unlcfs this be at- 
tended to, it is impoffible in any cafe to 
M m 2 re- 



540 0/ Chronic or Ch. XXXVIII. 

remove them. Various remedies are re- 
commended for the cure or removal of 
corns. The molt efFedual I have ever 
tried, Is the paring off ali tlie inorganic 
Dart of them, after bathing for the fpace 
of half an hour or fo in warm water, 
and immediately thereafter applying 
over them flips of foft leather fpread wiih 
empladrum gummofum. Ifthefoaking 
in water and paring the corns be re- 
peated from time to time, and the appli- 
cation of this plader be continued, the 
corns will be kept eafy, and the hard 
knots v/ill often fcparate and fall out ; 
when, if prefTiire be avoided, the vacancy 
produced by their removal will foon fill 
up with cellular fubftance, and no return 
of them will be experienced. 



§ i/^. Of a.ftmple Exojiofis, Venereal . Nodes, ^and 
Spina Ventofa. 

An Exodofis is an indolent hard tu- 
mor originating from a bone. In fomc 

cafes 



Se£l. III. Indolent Tumors. 541 

cafes it is altogether a local afFedliion ; 
being produced by a ruperabundant cal- 
lus in frartured bones ; by bones being 
deeply wounded, or their fubftance ero- 
ded by an ulcer. In others, it appears as 
the fymptom of fome general affedion of 
the fyfleni, particularly of the lues ve-, 
nerea and Icrophula. In the (irfl; of 
•thefe difeafes, the tumor is termed a Ve- 
nereal Node. When it appears as a fymp- 
tom of fcrophula, which it frequently 
does, it is ufually termed a Spina Ventofa. 
Exoftofes, when local, and proceeding 
from an effufion of ofTeous matter in frac- 
tured or wounded bones, are feldom 
attended with pain ; and after arriving 
at a certain fize, they commonly remain, 
ftationary. But when, they originate 
from an internal caufe, they are com- 
monly-painful from the firft ; probably 
from the diftention of the periofteum, 
which being a firm membrane, and clofe- 
ly attached to the bone beneath, does 
not readily yield to the tumefadlion. 
And in this cafe thefwelling continues to 
M m 3 advance. 



542 Of Chronic or Ch. XXXVIII. 

advance, either till it burfts into a fore, 
or till the difeafe in the conftitution by 
which it was produced be eradicated. 

In venerea] nodes, the periofteum is 
often found inflamed and much thicken- 
ed ; and in fome cafes a fmall quantity 
of a thin acrid ferum is efFufed between 
this membrane and the bones. Hence, 
in thofe cafes, the fwelling in the bonq 
appears to be much larger than it 
really is ; for on being laid open, it is 
often found to be inconfiderable wherj 
compared with the previous fize of the 
tumor. This has made fome fufpedt 
that the fwelling which we term a Node 
in lues venerea, is not originally an af- 
fedion of the bone, but a thickening of 
the periofteum, and that the bone only 
fuffers from its connedlion with this 
membrane. There is much reafon, how- 
ever, to imagine, that the reverfe of this 
is the cafe, and that the bone is the part 
primarily aflPe(5led. For it is worthy of 
remark, that it is in the advanced ftage§ 
of the fyphilis only, that the bones are 

m 



Se<2'. III. Indolent Ticmors. 543 

apt to be affeded ; and even then, that it 
is the hardeft parts of them, fuch as the 
fore-part of the tibia and the bones of 
the cranium, which are moft apt to fuf- 
fer. 

In fcrophulous patients we frequently 
find the whole fubftance of a bene fwell, 
particularly the extremities of the large 
bones forming . the joints of the knee, 
ankle, elbow, and wrift. Various con- 
je(5lures are met with in authors of the 
origin of the term Spina Ventofa given 
to this fwelling ; bvit whatever may have 
been the firO: caufe of it, or whether it 
be properly applied or not, we think it 
right to retain it, in order to prevent that 
qonfufion which is apt to enfue from dif- 
ferent names being given to the fame 
difeafe. 

In the fpina ventofa a pain is fir ft dif- 
covered in the affedled bone, and it is 
ufually fo deeply feated, that the patient 
is led to think from his feelings, that it 
proceeds from the very center of the 
Jijpne. This fometimes takes place for 
M m ^ fever?:! 



544 Of Chronic or Ch. XXX\rir. 

feveral days betore any Iwelling is per- 
ceived ; bui for the molt pait a flight de- 
gree of fulnefs is oblerved fiom the fiift. 
AVhen this orcurs m a patient with other 
fymptojns of Iciophula, and efpccially 
when it fixes on any c f the large joints, 
theie will be much cauie to luiped the 
nature of it, but it often happens that 
this is the firft fymptom of fcrophula, ef- 
pecially when it occurs in childhood: 
in which cafe both the parents and fur- 
geon are apt to fufpcd that it proceeds 
from a contufion oi Iprain ; nor does the 
dehifion ceafe with the former, till the 
difeafe becomes evident by breaking out 
in other parts of the body. 

When thefe fwcllings occur in the 
middle part of bones, as lometiuies 
happen in the bones of the hands and 
feet, they are apt to advance quickly ; 
^nd oh the foft parts burfling above them, 
a thin, ill corditioned matter is difchaf 
ged, and the bones are difcovered to be 
carious on the introduction of a probe. 
But when the difeafe fixes on any of the 

large 



Se£t. III. Indolent Tumors. 54c 

lar -e joints, although it feldom fails to 
termlaate in a fore at laft, yet it com- 
monly proceeds to this ftate in a more 
gradual manner ; nor does any remedy 
with which' we are acquainted prevent the 
progrefs of it. In this licuation it lays the 
foundation of what is ulually termed a 
Whice Swelling ; a difeaie we have for- 
merly conlidered at tall length *. 

Wlien thefe fwellings burft and termi- 
nate in fores, the fofc ipongy parts of the 
bones are found to be diflblved ; and on 
the matter which they produce being 
difcharged. the remaining cavities have 
the appearance of being formed by all 
the interior part of the bones having 
been icooped out, there being nothing 
left but a chin ofTeous covering formed 
ot the hard external lamella of the bone. 
In this ftate of the difeafe, the appear- 
ances which the bone exhibits are very fi- 
milar to thoie of fcrophulous fores in the 
fofter parts of the body : And as the fpina 
Ventofa is, in one ftage of it or another, 

almofl 

^ Vide Treatife on Ulcers, &c. Part III. 



545 • Of Chronic or Ch. XXXVIII. 

almofl: always accompanied with other 
fymptoms of fcrophula, I am clearly of 
opinion, as was elfewhere obferved, that 
we fhould confider it entirely as a fcro- 
phulous affedlion, it being the fame in the 
bones what fcrophula in its more ufual 
form is in the lymphatic glands. 

In the treatment of an exoftofis, the 
caufe by which the tumor fcems to have 
been induced requires particular atten- 
tion. Where it is perfedly local, and 
formed merely by an exuberance of cal- 
lus, although fome deformity may enfue 
from it, yet it is feldom produAive of fo 
much pain or inconvenience as to in- 
duce the patient to fpeak of it. But 
when tumors, even of this local kind, be- 
come fo large as to prove troublefome or 
painful, they neceffarily excite the atten- 
tion both of the patient and pradlitioner. 
As they are of a nature that will not 
yield to any medicine, we muft truft en^ 
tirely, in thofe cafes where it is neceffary 
to remove them, to a chirurgical operas 

tion. 

Thu 



Se£t. III. Indolent Tumors, 547 

The patient being placed upon a table, 
and properly fecured by affiftants, if 
there be any rifk of contiguous large ar- 
teries being cut, a tourniquet fhould ia 
the firft place be applied fo as to com- 
prefs them above: An.incifion fhould 
now be made through the teguments co- 
vering the tumor ; and in order to give 
fufficient freedom in the remaining fteps 
of the operation, it fhould not only be 
carried along the whole courfe of the 
fwelling, but an inch or even more pafl: 
each end of it, when it is fo fituated as to 
admit of it. The cut is now to be con- 
tinued down to the bone, at the fame 
time that the operator ihould avoid as 
much as poflible doing any injury to the 
contiguous mufcles, tendons, veins, ar- 
teries, and nerves. By a little attention 
to this part of the operation, much di- 
ftrcfs may be prevented, which might 
probably occur were it to be done in a 
^lore hurried manner. 

On the bone being laid bare, we are 
peptt to determine on the beft method of 

re- 



548 Of Chrome or Ch. XXXVIII. 

removing that part of it which torms the 
tumor: and this will depend upon the 
fize of it. If it is merely a fmall knob 
that can he adinittt d into the head of a 
trepan, it may be taken off with that in- 
ftrument : or \'i, it be too large for this, 
it may be removed with a common faw ; 
and after taking away any I'piculae which 
might create irritation, the lore may be 
treated Uke wounds produced in any o- 
ther manner. The loft parts lliould be 
drawn over the bone, and cLe edges of 
the fkin being laid together and fecured 
with adhehve plalters, a cure may pof^ 
fiblv be obtained by rhe firit intention. 
In tome cafes, indeed, this may be pre- 
vented by faiall exfoliations taking place 
from the fite of the tumor. I know, 
however, from experience, that it will 
fometimes fucceed, and therefore I would 
always advife it to be attempted ; for 
even where fmall exfoliations take place, 
the pieces of bone vvill be forced to the 
furface, and may be afterwards taken 

ouc 



Sefl:. III. Indolent Tumors. 549 

out long after the cure of the foft parts 
is completed. 

An exoflofis, however, is fometimes 
found to furround a bone entirely. In 
this cafe the treatment now advifed will 
not apply. In tliis lituation, that portion 
of the bone muit be taken out on which 
the exoRofis is fixed, when the bone is of 
fuch a length and is fo fitnated as to ad- 
mit of it : But as this can fcarcely be 
done in the fmall bones of the hands and 
feet, when any of thefe are afFecfied, It 
becomes necefTary to remove the difea- 
fed bone entirely. In a cafe of this kind 
which occurred on one of the metatarfal 
bones, and where the exoflofis furround- 
ed the whole circumference of the bone, 
I thought it better to take out the bone 
altogether, than to leave the two ends of 
it only; The one operation was perform- 
ed with no great difficulty : the other 
would have been much more painful as 
well as more tedious, and it would not 
have proved more faccefsful. For al- 
thougli the part did not fill up with bone, 

it 



550 Of Chronic or Ch. XXXVIII. 

it became fufliciently firm to enable the 
patient to walk as well as he did before. 

In the long bones, however, of the 
thighs, legs, or arms, we may fafely ven- 
ture to remove any portion of them on 
which an exoClofis is fixed : and where 
the conftitution is healthy, we need never 
defpair of nature fijpplying the deficien- 
cy ; for inftances have been often met 
with, even of entire bones being regene- 
rated. When a portion of bone is to be 
removed, after laying it freely bare by 
an extenfive incifion, a piece of pafte- 
board, or a thin flieet of lead, fhould be 
palled beneath it, in order to protcft the 
parts below from the teeth of the faw. 
Where a portion of the fibula or tibia is 
to be removed, the fplint muft be pafTed 
in between thefe bones; and when either 
of the bones of the fore-arm are affe<n:ed, 
it muft be paflcd between the radius and 
ulna. Different forms of faws have been 
employed for dividing the bone ; but the 
common faw ufed in amputations an- 
fvvers better perhaps than any other. 

When the portion of bone is removed, 

the 



Se£t. III. Indolent Tumors. 551 

the fore fhould be drefled with the mild- 
eft applications ; a piece of foft line 
fpread with the common wax liniment, 
or merely dipped in oil, fhould be infert- 
ed between the lips 'of the wound ; and 
if any thing be employed for retaining 
them, it fhould be the many-tailed ban- 
dage, which can be undone without mo- 
ving the Umb. It is a matter of import- 
ance to place the limb in a fituation the 
moft favourable for the difcharge of mat^ 
ter ; and as the operator has it commonly 
in his power to make the wound more or 
lefs inclined to any fide of the limb, this 
circumftance fhould be attended to in the 
firft part of the operation. 

When the operation has been perform- 
ed upon either of the bones of the leg or 
fore-arm, the remaining found bone will 
always keep the limb at its full length, 
fo that there will be little or no rilk of 
its becoming fhorter. But when a por- 
tion of a fingle bone is taken out, fome 
attention is required to prevent the limb 
from becoming fhorter during the cure. 
For this purpofe different machines have 

been 



55^ Of Chronk or Ch. XXX VIII. 

been invented ; but I have never found 
any aiiiikn'ce o( this, kind neceflary : tor 
if ,the patient be informed of the great 
importance of keeping the limb in a pro- 
per po ft a re, he will give ic all the atten- 
tion that is rcquilite : and befides, .nmcli 
incoayenience, pain, and infl-iinmadon, 
are apt to enfue from any inilruinent em- 
play ed foiT this pnrpofe, v/hen applied 
7i^-^h.t€i%?^ tightnefs that is neceffa.ry for 
keep i rig a limb in a ilate of'extenfion. 
•'Buring the cure of .the fore, ,the chief 
obje6l is to prevent matter from lodging 
and palling between the contiguous found 
parts. If this be prevented, and the, hps 
of the wound be kept open by the eafy 
dreffings we have mentioned, Jtill it fills 
up with granuiatiohs from the bottom, 
the reft will be accomplifhed by nature 
alone. Thole f^U granulations which 
at firft: occupied all the vacancy between 
the ends cf the divided bones, will foon 
acquire the coofifltnce and ftrengih of 
bone ; and in the courfe of a (hort time, 
if Che general Hate of health continues 

, good 



Se£l. Iir. Indolent Tumors. r r^ 

good, the limb will become equally ufeful 
as it was before. 

Hitherto we have fuppofed the dif- 
eafe to be feated in the extremities. But 
tumors of this kind are alfo found in 
other parts of the body : on difFerenc 
pares of the ilcull ; on the under-jaw ; on 
the ribs and clavicles ; and I once faw a 
large exoftofis on the upper part of the 
fcalpula. But wherever they are fitua- 
ted, the treatment is the fame. While 
they give no uneafinefs, nothing fhould 
be done; for they will fometimes conti- 
nue fmall and ftationary for life : But 
"when they increafe and prove troublefome, 
the fooner they are removed the better ; 
for the earlier the operation is perform- 
ed, the more eafily will it be done. 

In that variety of exoftofis termed a 
Node, proceeding from the lues venerea, 
the firft point to be determined is the 
Hate of the fyftem. The patient Ihould 
be immediately put upon fuch a courfe 
of mercury as can be depended upon for 
the removal of any infe<5lion he may la- 
bour under ; and if the tumqr in the 

Vol. V. N n bone 



554 Of Chronic or Ch. XXXVIU. 

bone be recent, and not far advanced, it 
may be carried off by the mercury alone. 
With a view, however, to make the me- 
dicine as effedlual as poiBble, it ftiould be 
thrown in as quickly, and in as great 
quantities, as the patient can bear : for 
the fyftem being completely infe(5led 
with the virus before nodes appear, it re- 
quires, for the mod part, a very confi- 
derable quantity of the medicine to 
check th^ir progrefs. 

At the fame time chat mercury is gi- 
ven inwardly, it is a common pradice ta 
rub the part itfelf with mercurial oint- 
ment, or to keep it covered with mer- 
curial plafter. I have never obferved, 
however, that any advantage is derived 
from this ; and 1 think it is apt to do 
harm. In tumors of this kind there is 
much reafon to fuppofe that the perio- 
fteum becomes inflamed from the firft. 
In diflferent inftances, the inflammation 
has appeared to be aggravated both by 
the application of plafters, and by the 
fridion ufed with mercurial ointment. 
Till we know whether the internal ex- 
hibition 



Se£l. III. Indolent Tumors. ^^^ 

hibition of mercury Is to prove efFedual 
or nor, fome mild fedative application, 
fuch as a folution of raccharumfaturni.or 
the unguent'vim nutritum, which is a pre- 
paration of lead, Qionld only be employed. 
Theie keep the parts eafy ; and by tend- 
ing to remove inflammation, they may 
even have fome influence in removing the 
tumor. 

But iC we find, after there is full evi- 
dence of the mercury having entered the 
fyfl:em, that the local affedlion of the 
bone ftill continues to advance, that the 
tumor becomes larger and the pain more 
fevere, other remedies fliould be advifed. 
In this fituation, I have fometimes found 
the pain relieved immediately by the 
application of feveral leeches over the 
tumor; and the pain being rendered mo- 
derate, we are thereby enabled to delay 
every other remedy till a more complete 
trial be given to the mercury. In fome 
cafes, where leeches have failed, bMfters 
applied dire(fl:ly upon the parts affected 
have proved fuccefsful. Neither they 
nor leeches can have any influence on the 
N n 2 original 



Ss6 Of Chmiic or Ch. XX-XVIIL. 

original difeafe : they will not leflcn the 
tumor of the bone ; but by leilenlng the 
tenfion of the perioflGum, they will prove 
more ulefal than perhaps any other re- 
medy we could employ. 

Sometimes, however, when thefe means 
are too long delayed ; ivhen the tumor 
advances with more rapidity than ufual ; 
or when acrid matter is perhaps confined 
beneath the periodeum;. neither leeches 
nor bllfters afford relief. In fuch cafes, 
an incifion made along the courfe of the 
tumor to the depth of the bone, will 
often give immediate eafe. The matter 
evacviated' from thefe tumors is frequent- 
ly a thin brown fanies:; at other times, it 
is a vifcid tranfparent mucus. 

In fome cafes the incifion heals kind- 
ly by common treatment, even when 
the tumor of the bone is by no means in- 
conliderable. Healthy granulations will 
form, and a cure of the fore will be ac- 
complifhed, even before the patient has 
taken as much mercury as may be judged 
neceilary for the cure of the difeafe. In 
fuch cafes, the tumefacflion of the bone is 

noE 



Sed. III. Indolent Tumors. rrj 

not to be regarded : It may probably, in- 
deed, continue during the life of the pa- 
tient ; but no inconveniency will after- 
wards enfue from it. So that unlefs it 
be fo fituated as to produ<:e much de- 
formity, it (hould never be touched. 

But, on other occafions, the fore, in- 
ftead of healing eafily, will remain ob- 
flinate, notwithftanding all the remedies 
that can be employed. In fuch circum- 
flances, the obftinacy in the fore is for 
the moft part fuppofed to arife from the 
venereal virus not being deftroyed, and a 
farther continuance of mercury is there- 
fore advifed. The mer<:urial courfe 
Ihould no doubt be carried fo far as- there 
is any chance of its proving ufeful. But 
, beyond this, it will commonly prove 
hurtful, and will rather tend to protract 
the cure of every fore. This, however, 
is a point upon which no precife direc- 
tions can be given ; the judgment of the 
pradlitioner in attendance muft deter- 
mine it. 

When the obflinacy of the fores de- 
pends upon other difeafes of the fyftem, 
N n 3 >^' the 



558 Of Chronic or Ch. XXXVIII. 

the removal of thefe will forward the 
cure. But when there feems to be a ten- 
dency in the difeafed bone to exfoliate, 
the completion of this procefs will alone 
prove elfe(^ual. In fuch circumftances, 
the treatment adapted to promote exfo- 
liation ought to be purfued : But as we 
have elfewhere confidered this fubjedl ful- 
ly, it is unnecefTary now to enter upon it*. 
After all the difeafed parts of the bone 
are removed, the fore will for the mofl: 
part heal readily. But in fome cafes, 
fuch a fullnefs and thickening of the 
periofteum and other contiguous parts 
has been produced by the long continu- 
ance of the difeafe, that the cure Hill 
proceeds flowly. In fuch c.ircumftances, 
mild emollient applications do harm : 
and nothing in general proves fo ufeful 
as thofe ointments that are ftrongly im- 
pregnated with red precipitate, or with 
verdigris. In fome cafes, even thefe do 
not act very fpeedily ; when touching the 
furface of the fore, once in two or three 
days, with lunar cauftic or with lapis in- 

fernalis, 

* Vide Treatife on Ulcers, 5c c. Pjrt 11. Seft. VII, 



Bed:. IIT. Indolent Tumors. 559 

fernalis, will make the Houghs throw off, 
and for the tnod part their place will be 
fupplied by healthy granulations ; after 
which, the cure will probably proceed 
■without interruption. 

In defcribing this variety of exoftofis, 
we have repeatedly mentioned the pain 
which attends it ; a fymptom which al- 
ways takes place ; at lealt I never met 
with an inftance of the contrary. Vene- 
real nodes, particularly thofe on the head, 
are not indeed always accompanied with 
much pain, but merely with a flight un- 
eafinefs. But this variety of node does 
not originate from the bone, but proceeds 
merely from an affed;ion of the periofte- 
um. In this cafe the tumor commonly 
fubiides entirely, either by the effeds 
of mercury alone, or by the application 
of a blifter ; and no advantage is derived 
from making an incifion into it. But in 
the other, if the bone be afFeded in any 
confiderable degree, the tumor never fub- 
iides, if it be not by a portion of the 
bone exfoliating. Even after every other 
fymptom of the difeafe is removed, thefe 
N n 4 tumors 



560 Of Chronic or Ch. XXXVIII, 

tumors in the bones continue equally 
fixed and large as they were at firft. We 
judge that a node proceeds fcom the 
boneitfelf; by the pain, as wehavejuft 
oblervcd, being in general acute ; by the 
tumor being confiderably harder than 
■when the periofteum only is afFedled ; 
by its advancing much more flowly than 
the other ; and by its continuing fixed 
and permanent, notwithftandmg all the 
remedies we can employ to remove it. 

We come now to fpeak of the treat- 
ment of the fpina ventofa, or that varie- 
ty of exoftofia which we fuppofe to ori- 
ginate from fcrophula ; and I am forry to 
obferve, that I have nothing fatisfadory 
to offer upon it. Fomentations, oint- 
ments, plafters, and a variety of other 
remedies, are recommended ; but 1 know 
of none that any advantage has ever been 
derived frorii. Tumors of this kind 
which appear formidable at firft, will 
fometimes indeed continue flationary, 
either from the fcrophulous difpofition 
in the fyflem being checked by cold- 
bathing, or fome other fimilar remedy; 

or ' 



Sed. III. Indolent Tumors, 561 

or from fome change taking place in the 
conftitution, with the nature of which 
we are perhaps altogether unacquainted. 
But this is a rare occurrence: for in ge- 
neral, notwithftanding all the remedies 
we employ, a fpina ventofa, from its firfl: 
appearance, proceeds in a gradual man- 
ner to turn worfe. 

When the difeafe appears at the fame 
time in different parts of the body, all 
we can with propriety attempt, is to fup- 
port the conftitution with a proper diet. 
To ad vile bark and cold bathing as the 
belt ftrengthening remedies ; and when 
the pain is fevere, to endeavour to render 
it moderate by adequate dofes of opium. 
But when it is confined to one part, as 
often happens in the knee and other 
large joints, in cafes of white fwclling, 
it becomes frequently advifeable to re- 
move the dileaied part by an operation. 
In affecflions of the joints, it has been, 
the common pradice in this fituation to 
amputate the difeafed limbs entirely. But 
an attempt has lately been made by Mr 
^3rk, an ingenious furgeon in Liverpool, 

tQ 



562 Of Chronic or Indolent Tumors. 

to fave the limbs that are thus .difeafed, 
by removing the heads of the afFetfled 
bones only, and afterwards healing the 
fore at which they were taken out. "When 
we come to treat of the operation of am- 
putation, we fliall enter more fully into 
the confideration of this ; for we think 
it highly deferving of notice : and at pre- 
fent fliall only remark, that there is caufe 
to fufpedl that it will not be found to 
prove fo generally ufeful, as at firfl view 
might be expe(^\ed. But in local fwell- 
ings of this kind which occur on the mid- 
dle of bones, we think it right to obferve, 
that the fame pradiice may be purfued 
which we have already recommended for 
the removal of thofe cafes of exoftofes 
which proceed from external violence : 
The fwelled portion of bone may be cut 
out when it is fituated on any of the 
long bones of the extremities ; and on 
any of the fhort bones of the hands or 
feet, the difeafed bones may be removed 
entirely. 

E X P L A- 



1M..VIK IjXIX 




h.. 



PI..A1'11 I.XVIU 




PL. Aim LXVU 







EXPLANATION of the PLATES. 
Plate LXVIL 

[Oppofite to page 59.3 

Figures i. 2. 3. and 4. are difFerenc 
reprefentations of the edges of wounds 
drawn together, and retahied by adhe- 
five plafters, as mentioned in page ^S, 
Plate LXVIIL 

[Oppofite to page 145.] 

The different figures in this plate re- 
prefent an apparatus for the cure of a 
rupture of the tendo Achillis. An ex- 
pli nation of it is given in p. 145, Sec, 
Plate LXIX. 

[Oppofite to page 178.] 

The figure in this plate is the inven- 
tion of Mr Chabert of Paris, and is taken 
from the fecond volume of Memoirs of 
the Royal Academy of Surgery : It is 
the bed inftrument that has yet been 
publifiied for comprefling the jugular 
veins. 

It 



5$4 Explanation of the Plates, 

It confifts of two curved pieces of 
fteel, A A^ conneded by a joint at the 
back-part of the machine, D. One of 
the fides terniinates in a horizontal plate, 
B ; the teeth of which paiUng through a 
hole in the oppofite plate, the prefTure 
made with it may be increafed or diminifli- 
ed at pleafure^ The cufhion, C, is meant to 
be placed upon the jugular vein, either 
upon a bleeding orifice in cafes of hemor- 
rhagy, or immediately below the opening 
to be made into it where blood is to be 
taken from this vein. This cufhion 
fhould be moveable, fo as to pafs with 
€afe from one part of the inftrument to 
another. Every part of the machine, ex- 
cepting the plate By ihould be covered 
with foft leather. 



End of the Fifth Volume. 



In the Prefs and Jpeedily twill be ■puhlijhed, by C. Elliot and T. Kay, 

No. 2,Z'^- Strand, London, and C. Elliot at Edinburgh, 

THE Philofophy of Natural Hiftory. By William Smellie, Mf-tnber 
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quarto. 

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DR. DANIEL C. ELKIN 

EMORY UKIV RbUY HOSPITAL 

EMORY UN.VERSITY, GEORGIA 



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